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Musallam KM, Barella S, Origa R, Ferrero GB, Lisi R, Pasanisi A, Longo F, Gianesin B, Forni GL. Differential effects of iron chelators on iron burden and long-term morbidity and mortality outcomes in a large cohort of transfusion-dependent β-thalassemia patients who remained on the same monotherapy over 10 years. Blood Cells Mol Dis 2024; 107:102859. [PMID: 38820707 DOI: 10.1016/j.bcmd.2024.102859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024]
Abstract
We conducted a retrospective cohort study on 663 transfusion-dependent β-thalassemia patients receiving the same iron chelation monotherapy with deferoxamine, deferiprone, or deferasirox for up to 10 years (median age 31.8 years, 49.9 % females). Patients on all three iron chelators had a steady and significant decline in serum ferritin over the 10 years (median deferoxamine: -170.7 ng/mL, P = 0.049, deferiprone: -236.7 ng/mL, P = 0.001; deferasirox: -323.7 ng/mL, P < 0.001) yet had no significant change in liver iron concentration or cardiac T2*; while noting that patients generally had low hepatic and cardiac iron levels at study start. Median absolute, relative, and normalized changes were generally comparable between the three iron chelators. Patients receiving deferasirox had the highest morbidity and mortality-free survival probability among the three chelators, although the difference was only statistically significant when compared with deferoxamine (P = 0.037). On multivariate Cox regression analysis, there was no significant association between iron chelator type and the composite outcome of morbidity or mortality. In a real-world setting, there is comparable long-term iron chelation effectiveness between the three available iron chelators for patients with mild-to-moderate iron overload.
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Affiliation(s)
- Khaled M Musallam
- Center for Research on Rare Blood Disorders (CR-RBD), Burjeel Medical City, Abu Dhabi, United Arab Emirates; Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Susanna Barella
- S.C. Centro delle Microcitemie e Anemie Rare, ASL Cagliari, Cagliari, Italy
| | - Raffaella Origa
- Università di Cagliari, S.C. Centro delle Microcitemie e Anemie Rare, ASL Cagliari, Cagliari, Italy
| | - Giovanni Battista Ferrero
- Hemoglobinopathies and Rare Anemia Reference Center, San Luigi Gonzaga University Hospital, Department of Biological and Clinical Sciences, University of Turin, Turin, Italy
| | - Roberto Lisi
- Thalassemia Unit, ARNAS Garibaldi, Catania, Italy
| | - Annamaria Pasanisi
- Centro della Microcitemia A.Quarta, Hematology Unit, A. Perrino Hospital, Brindisi, Italy
| | - Filomena Longo
- Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero Universitaria S. Anna, Ferrara, Italy
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Chun GY, Ng SSM, Islahudin F, Selvaratnam V, Mohd Tahir NA. Polypharmacy and medication regimen complexity in transfusion-dependent thalassaemia patients: a cross- sectional study. Int J Clin Pharm 2024; 46:736-744. [PMID: 38551751 DOI: 10.1007/s11096-024-01716-y] [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: 11/29/2023] [Accepted: 02/14/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Medication burden and complexity have been longstanding problems in chronically ill patients. However, more data are needed on the extent and impact of medication burden and complexity in the transfusion-dependent thalassaemia population. AIM The aim of this study was to determine the characteristics of medication complexity and polypharmacy and determine their relationship with drug-related problems (DRP) and control of iron overload in transfusion-dependent thalassaemia patients. METHOD Data were derived from a cross-sectional observational study on characteristics of DRPs conducted at a Malaysian tertiary hospital. The medication regimen complexity index (MRCI) was determined using a validated tool, and polypharmacy was defined as the chronic use of five or more medications. The receiver operating characteristic curve analysis was used to determine the optimal cut-off value for MRCI, and logistic regression analysis was conducted. RESULTS The study enrolled 200 adult patients. The MRCI cut-off point was proposed to be 17.5 (Area Under Curve = 0.722; sensitivity of 73.3% and specificity of 62.0%). Approximately 73% and 64.5% of the patients had polypharmacy and high MRCI, respectively. Findings indicated that DRP was a full mediator in the association between MRCI and iron overload. CONCLUSION Transfusion-dependent thalassaemia patients have high MRCI and suboptimal control of iron overload conditions in the presence of DRPs. Thus, future interventions should consider MRCI and DRP as factors in serum iron control.
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Affiliation(s)
- Geok Ying Chun
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300, Malaysia
| | - Sharon Shi Min Ng
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300, Malaysia
| | - Farida Islahudin
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300, Malaysia
| | - Veena Selvaratnam
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300, Malaysia
| | - Nurul Ain Mohd Tahir
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300, Malaysia.
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Lee WJ, Mohd Tahir NA, Chun GY, Li SC. The impact of chelation compliance in health outcome and health related quality of life in thalassaemia patients: a systematic review. Health Qual Life Outcomes 2024; 22:14. [PMID: 38302961 PMCID: PMC10835961 DOI: 10.1186/s12955-023-02221-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 12/13/2023] [Indexed: 02/03/2024] Open
Abstract
Understanding consequences of poor chelation compliance is crucial given the enormous burden of post-transfusional iron overload complications. We systematically reviewed iron-chelation therapy (ICT) compliance, and the relationship between compliance with health outcome and health-related quality of life (HRQoL) in thalassaemia patients. Several reviewers performed systematic search strategy of literature through PubMed, Scopus, and EBSCOhost. The preferred reporting items of systematic reviews and meta-analyses (PRISMA) guidelines were followed. Of 4917 studies, 20 publications were included. The ICT compliance rate ranges from 20.93 to 75.3%. It also varied per agent, ranging from 48.84 to 85.1% for desferioxamine, 87.2-92.2% for deferiprone and 90-100% for deferasirox. Majority of studies (N = 10/11, 90.91%) demonstrated significantly negative correlation between compliance and serum ferritin, while numerous studies revealed poor ICT compliance linked with increased risk of liver disease (N = 4/7, 57.14%) and cardiac disease (N = 6/8, 75%), endocrinologic morbidity (N = 4/5, 90%), and lower HRQoL (N = 4/6, 66.67%). Inadequate compliance to ICT therapy is common. Higher compliance is correlated with lower serum ferritin, lower risk of complications, and higher HRQoL. These findings should be interpreted with caution given the few numbers of evidence.
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Affiliation(s)
- Wan Jin Lee
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Ain Mohd Tahir
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
| | - Geok Ying Chun
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Shu Chuen Li
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, New South Wales, Australia
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Keowmani T, Teo SC, Yap KC, Chua WL, Mohd Tahir NF, Chua PW, Lim VC, Leong HH. Adherence to Iron Chelation Therapy Among Children with Beta Thalassemia Major: A Multicenter Cross-Sectional Study. Hemoglobin 2023; 47:237-244. [PMID: 38111324 DOI: 10.1080/03630269.2023.2295291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Adherence to iron chelation therapy (ICT) remains an issue among thalassemia patients. This study aimed to determine the prevalence of non-adherence to ICT among children with beta thalassemia major in Malaysia and the factors associated with it. METHODS This was a cross-sectional study conducted between November 2019 and November 2021 at seven tertiary hospitals in Malaysia. Participants registered with Malaysian Thalassemia Registry were recruited by convenience sampling. Adherence was measured via pill count and self-reported adherence. Knowledge about thalassemia and ICT was measured using a questionnaire from Modul Thalassemia by Ministry of Health of Malaysia. A decision tree was used to identify predictors of non-adherence. RESULTS A total of 135 patients were recruited. The prevalence of non-adherence to ICT in those who took subcutaneous ± oral medications was 47.5% (95% CI: 31.5%, 63.9%) and the prevalence of non-adherence to ICT in those who took oral medications only was 21.1% (95% CI: 13.4%, 30.6%). The median knowledge score was 67.5% (IQR 15%). A decision tree has identified two factors associated with non-adherence. They were ICT's route of administration and knowledge score. Out of 100 patients who were on oral medications only, 79 were expected to adhere. Out of 100 patients who were on subcutaneous ± oral medications and scored less than 56.25% in knowledge questionnaire, 86 were expected to non-adhere. Based on the logistic regression, the odds of non-adherence in patients who took oral medications only was 71% lower than the odds of non-adherence in patients who took subcutaneous ± oral medications (OR = 0.29; 95% CI = 0.13, 0.65; p = .002). CONCLUSION The prevalence of non-adherence to ICT among children with beta thalassemia major in Malaysia was 20/95 (21.1%) in those who took oral medications only and the prevalence of non-adherence was 19/40 (47.5%) in those who took subcutaneous ± oral medications. The factors associated with non-adherence were ICT's route of administration and knowledge score.
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Affiliation(s)
- Thamron Keowmani
- Pharmacy Department, Hospital Wanita Dan Kanak-Kanak Sabah, Sabah, Malaysia
| | - Siew Chin Teo
- Pharmacy Department, Hospital Wanita Dan Kanak-Kanak Sabah, Sabah, Malaysia
| | - Kuan Chau Yap
- Pharmacy Department, Hospital Tunku Azizah, Kuala Lumpur, Malaysia
| | - Wei Lian Chua
- Pharmacy Department, Hospital Raja Perempuan Zainab II, Kelantan, Malaysia
| | | | - Peck Wei Chua
- Pharmacy Department, Hospital Tengku Ampuan Afzan, Pahang, Malaysia
| | - V Co Lim
- Pharmacy Department, Hospital Ampang, Selangor, Malaysia
| | - Hoon Hing Leong
- Pharmacy Department, Hospital Queen Elizabeth, Sabah, Malaysia
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Touma H, Youssef LA, Al-Salhi L, Ismail Al-khalil W, AlKeba K. Prevalence and Management of Transfusional Iron Overload in Syrian Beta Thalassemia Major Patients Pre and during the Syrian Conflict. BIOMED RESEARCH INTERNATIONAL 2023; 2023:8911518. [PMID: 37743972 PMCID: PMC10513871 DOI: 10.1155/2023/8911518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/16/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023]
Abstract
Objectives The primary aim of this study was to evaluate the prevalence of iron overload and the real-world clinical effectiveness of the iron chelation therapies (ICTs) in Syrian patients with transfusion-dependent beta thalassemia major (BTM) prior to and during the ongoing Syrian conflict. Methods This single-center, two-stage observational study was conducted at Homs National Thalassemia Center (HNTC) prior to (2009) and during (2019) the armed conflict. The prevalence and the severity of iron overload, as well as the effectiveness of four iron chelation regimens, were assessed using serum ferritin (SF) concentrations as a means of monitoring in two cohorts of BTM patients receiving deferoxamine (DFO), deferiprone (DFP), deferasirox (DFX), or a combination of DFO and DFP therapy in both years. Statistical analyses encompassed one-way ANOVA, Kruskal-Wallis, Mann-Whitney U, and chi-square (χ2) tests for the comparisons of the variables and the frequencies between the two cohorts and subgroups. Results We included all eligible BTM patients at HNTC in 2009 (n = 205) and 2019 (n = 172). Only 84 patients from the 2009 cohort were accessible in 2019. Our findings revealed that 98% and 89% of the patients had iron overload (SF ≥ 1500 ng/mL) and comparable elevated median SF concentrations (3868 and 3757 ng/mL) in 2009 and 2019, respectively (P = 0.275). Furthermore, patients on DFO demonstrated the poorest control of iron overload and the highest SF concentrations (4319 and 5586 ng/mL), whereas those on DFX achieved superior outcomes and the lowest SF concentrations (3355 and 2152 ng/mL) in both years. Twenty-six patients from the 2019 cohort received no ICT for six years (from 2012 to 2018) and experienced extremely severe iron overload with SF levels ranging between 4481 and 16,000 ng/mL. Conclusions Our findings prove a high prevalence of iron overload and suboptimal chelation outcomes in Syrian BTM patients, both prior to and during the ongoing armed conflict, despite the provision of free ICTs at HNTC. Poor adherence and older age of patients may explain the unfavorable outcomes of DFO and (DFO+DFP) regimens, whereas younger age and higher socioeconomic status may have contributed to the lowest SF and superior outcomes in patients on DFX. This study also demonstrates the crucial role of the National Thalassemia Centers, namely HNTC, in providing health services to BTM patients in times of peace and conflict.
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Affiliation(s)
- Hanan Touma
- Program of Clinical and Hospital Pharmacy, Department of Pharmaceutics & Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syria
- University of Kalamoon, Deir Atiyah, Damascus, Syria
| | - Lama A. Youssef
- Program of Clinical and Hospital Pharmacy, Department of Pharmaceutics & Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syria
| | - Lana Al-Salhi
- Program of Clinical and Hospital Pharmacy, Department of Pharmaceutics & Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syria
| | - Wouroud Ismail Al-khalil
- Program of Clinical and Hospital Pharmacy, Department of Pharmaceutics & Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syria
| | - Khawla AlKeba
- National Thalassemia Center, Homs, Syria
- Al-Ahli Hospital, Homs, Syria
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Sawh RN. The patient perspective: The struggles of living with thalassemia as an adult. Ann N Y Acad Sci 2023; 1527:20-24. [PMID: 37468233 DOI: 10.1111/nyas.15040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Today it has become the norm for individuals diagnosed with severe forms of thalassemia who have access to hypertransfusion regimens, chelation therapy, and annual surveillance to survive well beyond childhood. However, with this improvement in prognosis and subsequent transition to adult care, it has become apparent that most adult healthcare providers, including many adult hematologists and primary care providers, are ill-prepared to care for these patients and the complications that accompany their survival into adulthood. Collaborative efforts are needed to develop comprehensive approaches to contend with the challenges faced by adult patients to ensure they are properly managed and supported.
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Affiliation(s)
- Radhika N Sawh
- The Joan H. Marks Graduate Program in Human Genetics, Sarah Lawrence College, Bronxville, New York, USA
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Abstract
Conventional therapy for severe thalassemia includes regular red cell transfusions and iron chelation therapy to prevent and treat complications of iron overload. Iron chelation is very effective when appropriately used, but inadequate iron chelation therapy continues to contribute to preventable morbidity and mortality in transfusion-dependent thalassemia. Factors that contribute to suboptimal iron chelation include poor adherence, variable pharmacokinetics, chelator adverse effects, and difficulties with precise monitoring of response. The regular assessment of adherence, adverse effects, and iron burden with appropriate treatment adjustments is necessary to optimize patient outcomes.
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Affiliation(s)
- Janet L Kwiatkowski
- Division of Hematology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, 3501 Civic Center Boulevard, Clinical Hub Building, Room 13547, Philadelphia, PA 19104, USA.
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Shah R, Shah A, Badawy SM. An evaluation of deferiprone as twice-a-day tablets or in combination therapy for the treatment of transfusional iron overload in thalassemia syndromes. Expert Rev Hematol 2023; 16:81-94. [PMID: 36755516 PMCID: PMC9992344 DOI: 10.1080/17474086.2023.2178409] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/06/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Regular blood transfusions in patients with thalassemia syndromes can cause iron overload resulting in complications including cirrhosis, heart problems, or endocrine abnormalities. To prevent iron overload toxicity in these patients, three iron chelators are currently FDA-approved for use: deferoxamine, deferasirox, and deferiprone. In the United States, deferiprone has been approved for three times daily dosing since 2011 and has recently gained approval for twice-daily administration. AREAS COVERED A PubMed literature search was performed with the keywords 'deferiprone' and 'thalassemia.' Relevant original research studying deferiprone's effects on transfusional iron overload in patients with thalassemia syndromes was included. Exclusion criteria included case reports and review papers. Deferiprone is effective at reducing serum ferritin levels in patients with iron overload. Twice-daily administration provides a similar level of iron chelation as three times daily dosing with a comparable side effect profile and increased patient acceptability. EXPERT OPINION New studies are highlighting deferiprone's potential for combination therapy with either deferoxamine or deferasirox to improve iron chelation. Deferiprone's ability to significantly decrease cardiac and liver iron content can be utilized in other transfusion-dependent hematologic conditions, as evidenced by its recent approval for use in the United States for sickle cell disease or other anemias.
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Affiliation(s)
- Richa Shah
- Division of Hematology, Oncology, and Stem Cell Transplant, Lurie Children’s Hospital of Chicago, Chicago, IL, 60611, USA
| | - Aashaka Shah
- University of Illinois College of Medicine, Chicago, IL, 60612, USA
| | - Sherif M. Badawy
- Division of Hematology, Oncology, and Stem Cell Transplant, Lurie Children’s Hospital of Chicago, Chicago, IL, 60611, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
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Reddy PS, Locke M, Badawy SM. A systematic review of adherence to iron chelation therapy among children and adolescents with thalassemia. Ann Med 2022; 54:326-342. [PMID: 35103514 PMCID: PMC8812788 DOI: 10.1080/07853890.2022.2028894] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Iron chelation therapy (ICT) is essential to prevent complications of iron overload in patients with transfusion-dependent thalassaemia. However, there is currently no standard for how to best measure adherence to ICT, nor what level of adherence necessitates concern for poor outcomes, especially in paediatric patients. The objectives of this review are to identify rates of adherence to ICT, predictors of adherence, methods of measurement, and adherence-related health outcomes in children and adolescents. METHODS This review covers the literature published between 1980 and 2020 on ICT in thalassaemia that assessed adherence or compliance. Included studies reflect original research. The preferred reporting items of systematic reviews and meta-analyses (PRISMA) guidelines were followed for reporting results, and the findings were critically appraised with the Oxford Centre for Evidence-based Medicine criteria. RESULTS Of the 543 articles, 37 met the inclusion criteria. The most common methods of assessing adherence included patient self-report (n = 15/36, 41.7%), and pill count (n = 15/36, 41.7%), followed by subcutaneous medication monitoring (5/36, 13.8%) and prescription refills (n = 4/36, 11.1%). Study sizes ranged from 7 to 1115 participants. Studies reported adherence either in "categories" with different levels of adherence (n = 29) or "quantitatively" as a percentage of medication taken out of those prescribed (n = 7). Quantitatively, the percentage of adherence varied from 57% to 98.4% with a median of 89.5%. Five studies focussed on interventions, four of which were designed to improve adherence. Studies varied in sample size and methods of assessment, which prohibited performing a meta-analysis. CONCLUSIONS Due to a lack of clinical consensus on how adherence is defined, it is difficult to compare adherence to ICT in different studies. Future studies should be aimed at creating guidelines for assessing adherence and identifying suboptimal adherence. These future efforts will be crucial in informing evidence-based interventions to improve adherence and health outcomes in thalassaemia patients.Key messagesPredictive factors associated with ICT adherence in the paediatric population include age, social perception of ICT, social support, and side effects/discomfort.Increased adherence in the paediatric population is associated with decreased serum ferritin and improved cardiac, hepatic, and endocrine outcomes.Inadequate adherence to ICT is associated with increased lifetime health costs.There are few studies that focussed on interventions to increase adherence in the paediatric population, and the studies that do exist all focussed on different types of interventions; successful interventions focussed on consistent, long-term engagement with patients.
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Affiliation(s)
- Paavani S Reddy
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Margaret Locke
- Department of Internal Medicine, Zucker School of Medicine at Hofstra/Northwell Institute, Hempstead, NY, USA
| | - Sherif M Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Hematology, Oncology, and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Feng W, Xiao Y, Zhao C, Zhang Z, Liu W, Ma J, Ganz T, Zhang J, Liu S. New Deferric Amine Compounds Efficiently Chelate Excess Iron to Treat Iron Overload Disorders and to Prevent Ferroptosis. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2202679. [PMID: 36031399 PMCID: PMC9561787 DOI: 10.1002/advs.202202679] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/04/2022] [Indexed: 05/09/2023]
Abstract
Excess iron accumulation occurs in organs of patients with certain genetic disorders or after repeated transfusions. No physiological mechanism is available to excrete excess iron and iron overload to promote lipid peroxidation to induce ferroptosis, thus iron chelation becomes critical for preventing ion toxicity in these patients. To date, several iron chelators have been approved for iron chelation therapy, such as deferiprone and deferoxamine, but the current iron chelators suffer from significant limitations. In this context, new agents are continuously sought. Here, a library of new deferric amine compounds (DFAs) with adjustable skeleton and flexibility is synthesized by adopting the beneficial properties of conventional chelators. After careful evaluations, compound DFA1 is found to have greater efficacy in binding iron through two molecular oxygens in the phenolic hydroxyl group and the nitrogen atom in the amine with a 2:1 stoichiometry. This compound remarkably ameliorates iron overload in diverse murine models through both oral and intravenous administration, including hemochromatosis, high iron diet-induced, and iron dextran-stimulated iron accumulation. Strikingly, this compound is found to suppress iron-induced ferroptosis by modulating the intracellular signaling that drives lipid peroxidation. This study opens a new approach for the development of iron chelators to treat iron overload.
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Affiliation(s)
- Wenya Feng
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085P. R. China
- University of Chinese Academy of SciencesBeijing100049P. R. China
| | - Yuanjing Xiao
- School of Chemistry and Molecular EngineeringEast China Normal University500 Dongchuan RoadShanghai200241P. R. China
| | - Chuanfang Zhao
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085P. R. China
- University of Chinese Academy of SciencesBeijing100049P. R. China
| | - Zhanming Zhang
- Department of ChemistryFudan University2005 Songhu RoadShanghai200438P. R. China
| | - Wei Liu
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085P. R. China
- University of Chinese Academy of SciencesBeijing100049P. R. China
| | - Juan Ma
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085P. R. China
- University of Chinese Academy of SciencesBeijing100049P. R. China
| | - Tomas Ganz
- Department of MedicineDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCA90095USA
| | - Junliang Zhang
- Department of ChemistryFudan University2005 Songhu RoadShanghai200438P. R. China
| | - Sijin Liu
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085P. R. China
- University of Chinese Academy of SciencesBeijing100049P. R. China
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Lee YC, Yen CT, Lee YL, Chen RJ. Thalassemia Intermedia: Chelator or Not? Int J Mol Sci 2022; 23:ijms231710189. [PMID: 36077584 PMCID: PMC9456380 DOI: 10.3390/ijms231710189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022] Open
Abstract
Thalassemia is the most common genetic disorder worldwide. Thalassemia intermedia (TI) is non-transfusion-dependent thalassemia (NTDT), which includes β-TI hemoglobin, E/β-thalassemia and hemoglobin H (HbH) disease. Due to the availability of iron chelation therapy, the life expectancy of thalassemia major (TM) patients is now close to that of TI patients. Iron overload is noted in TI due to the increasing iron absorption from the intestine. Questions are raised regarding the relationship between iron chelation therapy and decreased patient morbidity/mortality, as well as the starting threshold for chelation therapy. Searching all the available articles up to 12 August 2022, iron-chelation-related TI was reviewed. In addition to splenectomized patients, osteoporosis was the most common morbidity among TI cases. Most study designs related to ferritin level and morbidities were cross-sectional and most were from the same Italian study groups. Intervention studies of iron chelation therapy included a subgroup of TI that required regular transfusion. Liver iron concentration (LIC) ≥ 5 mg/g/dw measured by MRI and ferritin level > 300 ng/mL were suggested as indicators to start iron chelation therapy, and iron chelation therapy was suggested to be stopped at a ferritin level ≤ 300 ng/mL. No studies showed improved overall survival rates by iron chelation therapy. TI morbidities and mortalities cannot be explained by iron overload alone. Hypoxemia and hemolysis may play a role. Head-to-head studies comparing different treatment methods, including hydroxyurea, fetal hemoglobin-inducing agents, hypertransfusion as well as iron chelation therapy are needed for TI, hopefully separating β-TI and HbH disease. In addition, the target hemoglobin level should be determined for β-TI and HbH disease.
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Affiliation(s)
- Yen-Chien Lee
- Department of Medical Oncology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
- Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan
- Correspondence: (Y.-C.L.); (R.-J.C.)
| | - Chi-Tai Yen
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
| | - Yen-Ling Lee
- Department of Medical Oncology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
| | - Rong-Jane Chen
- Department of Food Safety/Hygiene and Risk Management, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Correspondence: (Y.-C.L.); (R.-J.C.)
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Locke M, Reddy PS, Badawy SM. Adherence to Iron Chelation Therapy among Adults with Thalassemia: A Systematic Review. Hemoglobin 2022; 46:201-213. [PMID: 35930250 PMCID: PMC9948767 DOI: 10.1080/03630269.2022.2072320] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Iron chelation therapy (ICT) is essential to prevent complications of iron overload in patients with transfusion-dependent thalassemia. However, the role that adherence to ICT plays in health-related outcomes is less well known. Our objectives were to identify adherence rates of ICT, and to assess methods of measurement, predictors of adherence, and adherence-related health outcomes in the literature published between 1980 and 2020. Of 543 articles, 43 met the inclusion criteria. Studies measured ICT adherence, predictors, and/or outcomes associated with adherence. Most studies were across multiple countries in Europe and North America (n = 8/43, 18.6%), recruited in clinics (n = 39/43, 90.7%), and focused on β-thalassemia (β-thal) (n = 25/43, 58.1%). Common methods of assessing ICT adherence included patient self-report (n = 24/43, 55.8%), pill count (n = 9/43, 20.9%), prescription refill history (n = 3/43, 7.0%), provider scoring (n = 3/43, 7.0%), and combinations of methods (n = 4/43, 9.3%). Studies reported adherence either in 'categories' with different levels of adherence (n = 24) or 'quantitatively' as a percentage of doses of medication taken out of those prescribed (n = 17). Adherence levels varied (median 91.7%, range 42.0-99.97%). Studies varied in sample size and methods of adherence assessment and reporting, which prohibited meta-analysis. Due to a lack of consensus on how adherence is defined, it is difficult to compare ICT adherence reporting. Further research is needed to establish guidelines for assessing adherence and identifying suboptimal adherence. Behavioral digital interventions have the potential to optimize ICT adherence and health outcomes.
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Affiliation(s)
- Margaret Locke
- Department of Internal Medicine, Zucker School of Medicine at Hofstra/Northwell Institute, Hempstead, NY, USA
| | - Paavani S. Reddy
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sherif M. Badawy
- Division of Hematology, Oncology, and Stem Cell Transplant, Ann & Robert H. Lurie Children’s Hospital of Chicago, IL, USA,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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13
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Wang H, Jiang C, Yang Y, Li J, Wang Y, Wang C, Gao Y. Resveratrol ameliorates iron overload induced liver fibrosis in mice by regulating iron homeostasis. PeerJ 2022; 10:e13592. [PMID: 35698613 PMCID: PMC9188311 DOI: 10.7717/peerj.13592] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/24/2022] [Indexed: 01/17/2023] Open
Abstract
This study is intended to explore the protective effects of resveratrol (RES) on iron overload-induced liver fibrosis and its mechanism. Iron dextran (50 mg/kg) was injected intraperitoneally in all groups except the control group. Mice in the L-RES, M-RES and H-RES groups were gavaged with RES solution at 25, 50 mg/kg and 100 mg/kg, respectively, 4 h before injection of iron dextran every day; mice in the deferoxamine (DFO) group were injected with DFO intraperitoneally (100 mg/kg); mice in the control group received isovolumetric saline. After seven weeks of RES administration, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) activities and liver hydroxyproline (Hyp) levels were reduced; the malondialdehyde (MDA) activities decreased and the levels of superoxide dismutase (SOD) and glutathione (GSH) were raised. Hematoxylin and eosin (H&E), Prussian, and Masson staining indicated that RES treatment could improve cell damage and reduce hepatic iron deposition and collagen deposition in iron-overload mice. The expression of Bcl-2 was increased, the expression levels of Bax and caspase-3 were decreased under RES treatment. Moreover, RES reduced the expression of hepcidin, ferritin (Ft), divalent metal transporter-1 (DMT-1), transferrin receptor-2 (TFR-2), and raised the expression of ferroprotein-1 (FPN-1). In conclusion, RES could ameliorate iron overload-induced liver fibrosis, and the potential mechanisms may be related to antioxidant, anti-inflammatory, anti-apoptotic, and more importantly, regulation of iron homeostasis by reducing iron uptake and increasing iron export.
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Affiliation(s)
- Hua Wang
- Hebei University of Chinese Medicine, Department of Preventive Medicine, Shijiazhuang, Hebei, China
| | - Chuan Jiang
- Hebei University of Chinese Medicine, Department of Preventive Medicine, Shijiazhuang, Hebei, China
| | - Yakun Yang
- Hebei University of Chinese Medicine, School of Pharmacy, Shijiazhuang, Hebei, China
| | - Jinghan Li
- Hebei University of Chinese Medicine, Department of Preventive Medicine, Shijiazhuang, Hebei, China
| | - Yihan Wang
- Hebei University of Chinese Medicine, Collge of Basic Medicine, Shijiazhuang, Hebei, China
| | - Chaonan Wang
- Hebei University of Chinese Medicine, Department of Preventive Medicine, Shijiazhuang, Hebei, China
| | - Yonggang Gao
- Hebei University of Chinese Medicine, Department of Preventive Medicine, Shijiazhuang, Hebei, China,Hebei Key laboratory of Chinese Medicine Research on Cardio-Cerebrovascular Disease, Shijiazhuang, Hebei, China
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14
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Perzia BM, Ying GS, Dunaief JL, Dunaief DM. Reduction in Ferritin Concentrations among Patients Consuming a Dark-Green Leafy Vegetable-Rich, Low Inflammatory Foods Everyday (LIFE) Diet. Curr Dev Nutr 2022; 6:nzac095. [PMID: 35769450 PMCID: PMC9233618 DOI: 10.1093/cdn/nzac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/28/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Ferritin is an iron-containing protein and acute-phase reactant, which may be elevated due to systemic iron overload or inflammation. Various diseases are associated with excess iron, but therapeutic iron chelation is suboptimal. Prior studies suggest that several plant phytochemicals possess iron-chelating properties, indicating that a plant-based diet may benefit patients with iron overload. Objectives The aim was to investigate whether patients who consume a nutrient-dense, dark-green leafy vegetable-rich diet, called the Low Inflammatory Foods Everyday (LIFE) diet, experience reductions in ferritin concentrations. Methods This was a retrospective study in which patients were intensively counseled to follow the LIFE diet. Compliance was assessed by patient interviews and serum B-carotene measurements. Primary outcomes included changes in ferritin, B-carotene, and C-reactive protein (CRP). Patients with elevated CRP concentrations at baseline were excluded in order to separate the impact of inflammation from iron overload on ferritin concentrations. Premenopausal women, who lose iron from menstruation, were also excluded. Results Thirty-two patients met the inclusion criteria. The median follow-up was 183 d. Following the dietary intervention, ferritin decreased (-81 μg/L, P = 0.006) and B-carotene increased (46 μg/L, P < 0.0001), whereas CRP remained unchanged (-0.02 mg/L, P = 0.86). Adherent patients had greater reductions in ferritin compared with nonadherent patients (-138 μg/L vs. 15 μg/L, P = 0.001). Among all patients, there was an inverse relation between B-carotene and ferritin (-2.02, P = 0.03). Conclusions The LIFE diet, or similar dark-green leafy vegetable-rich, whole-food plant-based diets, may benefit patients with disorders of iron overload and iron-induced oxidative stress.
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Affiliation(s)
| | - Gui-Shuang Ying
- Department of Ophthalmology, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua L Dunaief
- Department of Ophthalmology, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA, USA
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15
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Eziefula C, Shah FT, Anie KA. Promoting Adherence to Iron Chelation Treatment in Beta-Thalassemia Patients. Patient Prefer Adherence 2022; 16:1423-1437. [PMID: 35698633 PMCID: PMC9188463 DOI: 10.2147/ppa.s269352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/29/2022] [Indexed: 01/19/2023] Open
Abstract
Thalassaemia is one of the commonest inherited genetic disorders world-wide with around 25,000 births of the most severely affected transfusion dependent children annually. Patients with transfusion dependent thalassaemia require regular blood transfusions to maintain life but because of this will develop iron overload. To remove the excess iron, patients are required to take iron chelation therapy (ICT). ICT requires lifelong adherence to treatment to prevent end organ damage from developing. Many of these preventable complications make adherence to therapy more complex for patients. In this review, we focus on two commonly encountered patient scenarios and discuss how different psychological models and a relational theory can be used to understand and support adherence to treatment.
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Affiliation(s)
- Chinea Eziefula
- Camden & Islington NHS Foundation Trust, London, UK
- Psychology Services, Whittington Health NHS Trust, London, UK
| | - Farrukh T Shah
- Department of Haematology, Whittington Health NHS Trust, London, UK
- Medical Director for Transfusion, NHSBT, London, UK
- Correspondence: Farrukh T Shah, Department of Haematology, Whittington Health, Magdala Avenue, London, N19 5NF, Tel +44 0207 288 5144, Email
| | - Kofi A Anie
- London North West University Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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16
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Constantinou V, Papayanni PG, Mallouri D, Batsis I, Bouinta A, Papadopoulou D, Papadimitriou V, Kammenou M, Pantelidou D, Sotiropoulos D, Sakellari I, Anagnostopoulos A, Yannaki E. Case study of betibeglogene autotemcel gene therapy in an adult Greek patient with transfusion-dependent β-thalassaemia of a severe genotype. Br J Haematol 2021; 196:1401-1404. [PMID: 34957544 DOI: 10.1111/bjh.17965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Varnavas Constantinou
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Penelope-Georgia Papayanni
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Despina Mallouri
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Ioannis Batsis
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Asimina Bouinta
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Despoina Papadopoulou
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Vasiliki Papadimitriou
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Maria Kammenou
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | | | - Damianos Sotiropoulos
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Ioanna Sakellari
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Achilles Anagnostopoulos
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Evangelia Yannaki
- Gene and Cell Therapy Center of the Hematology Department/Hematopoietic Cell Transplantation Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
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17
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Badawy SM, Kattamis A, Ezzat H, Deschamps B, Sicard E, Fradette C, Zhao F, Tricta F, Chung Tsang Y, Sheth S, Piga A. The safety and acceptability of twice-daily deferiprone for transfusional iron overload: A multicentre, open-label, phase 2 study. Br J Haematol 2021; 197:e12-e15. [PMID: 34931307 PMCID: PMC9303221 DOI: 10.1111/bjh.17999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/22/2021] [Accepted: 12/01/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Sherif M Badawy
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Antonis Kattamis
- National and Kapodistrian University of Athens, 'Aghia Sophia' Children's Hospital, Athens, Greece
| | - Hatoon Ezzat
- St Paul's Hospital, Vancouver, British Columbia, Canada
| | | | | | | | - Feng Zhao
- Chiesi Canada Corporation, Toronto, Ontario, Canada
| | | | | | - Sujit Sheth
- New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
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18
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Chat Chai AS, Draman N, Mohd Yusoff SS, Azman NF, Zulkifli MM, Yaacob NM, Mohamad N, Hassan R, Abdullah WZ, Zilfalil BA. Non-compliance to iron chelation therapy in patients with transfusion-dependent thalassaemia. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2021. [DOI: 10.1016/j.phoj.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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19
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Zengin Ersoy G, Ayçiçek A, Odaman Al I, Bayram C, Arslantaş E, Özdemir GN, Uysalol EP, Şalcıoğlu Z, Akıcı F, Aydoğan G. Safety and efficacy of deferasirox in patients with transfusion-dependent thalassemia: A 4-year single-center experience. Pediatr Hematol Oncol 2021; 38:555-563. [PMID: 33749500 DOI: 10.1080/08880018.2021.1901809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This study was organized to determine the efficacy and safety of deferasirox (DFX) in reducing the SF of patients with transfusion-dependent thalassemia (TDT). This is a retrospective, descriptive study of 101 transfusion- dependent patients with thalassemia major who were followed for 48 months. Twenty-nine patients who used an alternative chelator either alone or combined, who were not compliant to the treatment, changed the drug due to adverse reactions, and had multiple transfusions and did not complete 4 years of DFX use were excluded. A total 72 out of 101 patients completed the study. SF decreases were noted for the 6-12 and >18-year age groups, from a median of 1532 ng/mL to 1190 ng/mL, and from 1386 ng/mL to 1165 ng/mL, respectively (p > 0.05). The proportion of patients with SF concentrations >2000 ng/mL is decreased (29% at baseline decreased to 15% at the end of the study) during the 48 months. The median SF of those who used <30 mg/kg/day (n = 38) increased from 767 ng/mL to 1006 ng/mL, whereas the >30 mg/kg/day (n = 34) group's SF concentrations decreased from a median of 1575 ng/mL to 1209 ng/mL (p = 0.029). The decrease of median SF values for Syrian patients was statistically significant (p = 0.043). Most common adverse events were gastric irritation symptoms (19.4%). The total DFX discontinuation ratio was calculated as 9.7%. Although dosages between 25-30 mg/kg/day are adequate to stabilize SF concentrations higher dosages are needed to achieve a statistically significant decrease.
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Affiliation(s)
- Gizem Zengin Ersoy
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Ali Ayçiçek
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Işık Odaman Al
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Cengiz Bayram
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Esra Arslantaş
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Gül Nihal Özdemir
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Ezgi Paslı Uysalol
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Zafer Şalcıoğlu
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Ferhan Akıcı
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Gönül Aydoğan
- Pediatric Hematology Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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20
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Chong CC, Redzuan AM, Sathar J, Makmor-Bakry M. Patient Perspective on Iron Chelation Therapy: Barriers and Facilitators of Medication Adherence. J Patient Exp 2021; 8:2374373521996958. [PMID: 34179377 PMCID: PMC8205330 DOI: 10.1177/2374373521996958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Nonadherence to iron chelation therapy (ICT) remains a long-standing and serious issue in thalassemia, especially in resource-constrained developing countries. Barriers and facilitators of adherence to ICT in transfusion-dependent thalassemia (TDT) adult patients in Malaysia are not completely understood. This qualitative study explored factors affecting adherence to ICT among TDT adult patients at a public tertiary hospital in Malaysia. Data were collected through 21 semistructured in-depth interviews conducted among purposively sampled patients using a pretested interview guide. All interviews were audio-recorded and transcribed verbatim. Data were analyzed manually using thematic analysis method and managed using Atlas.Ti software. The most frequently discussed subthemes of barriers to adherence included patient-related factors, medications-related factors, sociocultural-related factors, environmental context and resources, and patient–health care provider relationship factors. The facilitators to adherence included having insights of their illness, prevailing sources of motivation emphasizing on strong self-efficacy, low medication burden, and having enabling environment. This study has identified barriers and facilitators that are unique to Malaysian thalassemic adults related to medication adherence. Options for future multifaceted interventions are suggested.
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Affiliation(s)
- Chia Chee Chong
- Faculty of Pharmacy, Centre of Quality Management of Medicines, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adyani Md Redzuan
- Faculty of Pharmacy, Centre of Quality Management of Medicines, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Jameela Sathar
- Hematology Department, Hospital Ampang, Pandan Mewah, Ampang, Selangor, Malaysia
| | - Mohd Makmor-Bakry
- Faculty of Pharmacy, Centre of Quality Management of Medicines, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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21
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Sidhu S, Kakkar S, Dewan P, Bansal N, Sobti PC. Adherence to Iron Chelation Therapy and Its Determinants. Int J Hematol Oncol Stem Cell Res 2021; 15:27-34. [PMID: 33613898 PMCID: PMC7885136 DOI: 10.18502/ijhoscr.v15i1.5247] [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] [Indexed: 01/19/2023] Open
Abstract
Background: Thalassemia is a chronic disease requiring lifelong treatment. The adherence to regular iron chelation therapy is important to ensure complication-free survival and good quality of life. The study aim to assess the adherence to iron chelation therapy (ICT) in patients with transfusion-dependent thalassemia (TDT), evaluate various causes of non-adherence and study the impact of non-adherence on the prevalence of complications secondary to iron overload. Materials and Methods: Patients with TDT on ICT for > 6 months were enrolled in the study. Hospital records were reviewed for demographic details, iron overload status, treatment details, and the prevalence of complications. A study questionnaire was used to collect information on adherence to ICT, knowledge of patients, and the possible reasons for non-adherence. Results: A total of 215 patients with a mean age of 15.07+7.68 years and an M: F ratio of 2.2:1 were included in the study. Non-adherence to ICT was found in 10.7% of patients. Serum ferritin levels were significantly higher in the non-adherent group (3129.8+1573.2 µg/l) than the adherent population (2013.1+1277.1 µg/l). Cardiac as well as severe liver iron overload was higher in the non-adherent patients. No correlation was found between disease knowledge and adherence to ICT. Difficulties in drug administration and many medicines to be taken daily were statistically significant reasons for non-adherence. There was no difference in the co-morbidities arising due to the iron overload in the two groups. Conclusion: Nearly 11% of patients with TDT were non-adherent to ICT. Non-adherence results in higher iron overload.
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Affiliation(s)
- Sukhmani Sidhu
- Bachelor of Medicine and Bachelor of Surgery Student, Dayanand Medical College, Ludhiana, Punjab, India
| | - Shruti Kakkar
- Department of Pediatrics, Dayanand Medical College, Ludhiana, Punjab, India
| | - Priyanka Dewan
- Department of Pediatrics, Dayanand Medical College, Ludhiana, Punjab, India
| | - Namita Bansal
- Research & Development Unit, Dayanand Medical College, Ludhiana, Punjab, India
| | - Praveen C Sobti
- Guru Teg Bahadur Sahib Charitable Hospital, Ludhiana, Punjab, India
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22
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Shafie AA, Chhabra IK, Wong JHY, Mohammed NS. EQ-5D-3L health state utility values in transfusion-dependent thalassemia patients in Malaysia: a cross-sectional assessment. Health Qual Life Outcomes 2021; 19:10. [PMID: 33413416 PMCID: PMC7791838 DOI: 10.1186/s12955-020-01645-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE There is a gap of information describing the health state utility values (HSUVs) of transfusion-dependent thalassemia (TDT) patients in Malaysia. These values are useful in the assessment of health-related quality of life (HRQoL), economic evaluations and provide guidance to disease management decisions. The objective of this study was to estimate and derive HSUVs associated with the treatment and complications of TDT patients in Malaysia using the EQ-5D-3L instrument. METHODS A cross-sectional survey using the EQ-5D-3L instrument was conducted between May to September 2018 across various public hospitals in Malaysia. Using a multi-stage sampling, patients diagnosed with TDT and receiving iron chelating therapy were sampled. The findings on the EQ-5D-3L survey were converted into utility values using local tariff values. A two-part model was used to examine and derive the HSUVs associated with the treatment and complications of iron overload in TDT. RESULTS A total of 585 patients were surveyed. The unadjusted mean (SD) EQ-5D-3L utility value for TDT patients were 0.893 (0.167) while mean (SD) EQ VAS score was 81.22 (16.92). Patients who had more than two iron overload complications had a significant decline in HRQoL. Patients who were on oral monotherapy had a higher utility value of 0.9180 compared to other regimen combinations. CONCLUSION Lower EQ-5D-3L utility values were associated with patients who developed iron overload complications and were on multiple iron chelating agents. Emphasizing compliance to iron chelating therapy to prevent the development of complications is crucial in the effort to preserve the HRQoL of TDT patients.
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Affiliation(s)
- Asrul Akmal Shafie
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Science, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia. .,Institutional Planning and Strategic Centre, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia.
| | - Irwinder Kaur Chhabra
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Science, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia.,Pharmacy Department, Sabah Women and Children's Hospital, Ministry of Health Malaysia, Karung Berkunci No.187, 88996, Kota Kinabalu, Sabah, Malaysia
| | - Jacqueline Hui Yi Wong
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Science, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia.,Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Noor Syahireen Mohammed
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Science, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia.,Clinical Research Center, Hospital Sultanah Bahiyah, Ministry of Health Malaysia, KM 6, Jalan Langgar, 05460, Alor Setar, Kedah Darul Aman, Malaysia
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23
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Pinto VM, Forni GL. Management of Iron Overload in Beta-Thalassemia Patients: Clinical Practice Update Based on Case Series. Int J Mol Sci 2020; 21:E8771. [PMID: 33233561 PMCID: PMC7699680 DOI: 10.3390/ijms21228771] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022] Open
Abstract
Thalassemia syndromes are characterized by the inability to produce normal hemoglobin. Ineffective erythropoiesis and red cell transfusions are sources of excess iron that the human organism is unable to remove. Iron that is not saturated by transferrin is a toxic agent that, in transfusion-dependent patients, leads to death from iron-induced cardiomyopathy in the second decade of life. The availability of effective iron chelators, advances in the understanding of the mechanism of iron toxicity and overloading, and the availability of noninvasive methods to monitor iron loading and unloading in the liver, heart, and pancreas have all significantly increased the survival of patients with thalassemia. Prolonged exposure to iron toxicity is involved in the development of endocrinopathy, osteoporosis, cirrhosis, renal failure, and malignant transformation. Now that survival has been dramatically improved, the challenge of iron chelation therapy is to prevent complications. The time has come to consider that the primary goal of chelation therapy is to avoid 24-h exposure to toxic iron and maintain body iron levels within the normal range, avoiding possible chelation-related damage. It is very important to minimize irreversible organ damage to prevent malignant transformation before complications set in and make patients ineligible for current and future curative therapies. In this clinical case-based review, we highlight particular aspects of the management of iron overload in patients with beta-thalassemia syndromes, focusing on our own experience in treating such patients. We review the pathophysiology of iron overload and the different ways to assess, quantify, and monitor it. We also discuss chelation strategies that can be used with currently available chelators, balancing the need to keep non-transferrin-bound iron levels to a minimum (zero) 24 h a day, 7 days a week and the risk of over-chelation.
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Affiliation(s)
- Valeria Maria Pinto
- Centro della Microcitemia e delle Anemie Congenite Ente Ospedaliero Ospedali Galliera, Via Volta 6, 16128 Genoa, Italy;
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Tartaglione I, Origa R, Kattamis A, Pfeilstöcker M, Gunes S, Crowe S, Fagan N, Vincenzi B, Ruffo GB. Two-year long safety and efficacy of deferasirox film-coated tablets in patients with thalassemia or lower/intermediate risk MDS: phase 3 results from a subset of patients previously treated with deferasirox in the ECLIPSE study. Exp Hematol Oncol 2020; 9:20. [PMID: 32793403 PMCID: PMC7419189 DOI: 10.1186/s40164-020-00174-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/13/2020] [Indexed: 01/03/2023] Open
Abstract
Background Despite the proven benefits of iron chelation therapy (ICT) in the management of chronic iron overload and related complications, compliance to long-term ICT is challenging. Results from the ECLIPSE study, an open-label, randomized, multicenter, 2-arm, phase 2 study evaluated the safety of deferasirox dispersible tablet and film-coated tablet (FCT) formulations in patients with transfusion-dependent thalassemia (TDT) or very low, low, or intermediate risk myelodysplastic syndrome (MDS) treated over 24 weeks. Methods The aim of the current study (a 2-year, open-label, multicenter, single-arm, phase 3 study) is to evaluate the long-term safety and efficacy of deferasirox FCT in a subset of patients with TDT or lower/intermediate-risk MDS treated for 2 years after the completion of 24 weeks of treatment with deferasirox in the ECLIPSE phase 2 study. Results Of 53 patients enrolled, 34 (64.2%) completed treatment and study. Adverse events (AEs) reported in most patients (~ 70%) were of mild to moderate severity. Headache and diarrhea were the most frequently (> 25%) reported AEs. None of the serious AEs (including 1 death) were considered treatment related. No new safety signal was identified, and long-term safety of deferasirox FCT was consistent with the known safety profile of deferasirox. No major concerns associated with gastrointestinal tolerability, renal safety, or hematological abnormalities (thrombocytopenia/neutropenia) were reported during the 2 years. Patients receiving deferasirox FCT had a treatment compliance (by pill count) of ~ 90% and persistence (continuous use for ≥ 30 days) of > 95%. Reduction in serum ferritin level was almost consistent starting from week 2 across all post-baseline time points (relative reduction: month 6, 19%; month 12, 29%). Conclusions The results from this 2-year interventional study suggest that the recommended dosing of deferasirox FCT, with better tolerability, palatability, and compliance, offers a favorable option of ICT for long-term management of iron overload and associated complications in TDT. Trial registration ClinicalTrials.gov, NCT02720536. Registered 28 March 2016, https://www.clinicaltrials.gov/ct2/show/NCT02720536
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Affiliation(s)
- Immacolata Tartaglione
- Department of Woman, Child and of General and Specialist Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Raffaella Origa
- Ospedale Pediatrico Microcitemico "A.Cao," A.O. "G.Brotzu", Cagliari, Italy
| | - Antonis Kattamis
- Division of Pediatric Hematology-Oncology, First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | - Giovan Battista Ruffo
- U.O.C. Ematologia e Talassemia, A.O. Civico-Di Cristina-Benfratelli, Piazza Nicola Leotta 4, 90127 Palermo, Italy
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Kalle Kwaifa I, Lai MI, Md Noor S. Non-deletional alpha thalassaemia: a review. Orphanet J Rare Dis 2020; 15:166. [PMID: 32600445 PMCID: PMC7322920 DOI: 10.1186/s13023-020-01429-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/28/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Defective synthesis of the α-globin chain due to mutations in the alpha-globin genes and/or its regulatory elements leads to alpha thalassaemia syndrome. Complete deletion of the 4 alpha-globin genes results in the most severe phenotype known as haemoglobin Bart's, which leads to intrauterine death. The presence of one functional alpha gene is associated with haemoglobin H disease, characterised by non-transfusion-dependent thalassaemia phenotype, while silent and carrier traits are mostly asymptomatic. MAIN BODY Clinical manifestations of non-deletional in alpha thalassaemia are varied and have more severe phenotype compared to deletional forms of alpha thalassaemia. Literature for the molecular mechanisms of common non-deletional alpha thalassaemia including therapeutic measures that are necessarily needed for the understanding of these disorders is still in demand. This manuscript would contribute to the better knowledge of how defective production of the α-globin chains due to mutations on the alpha-globin genes and/or the regulatory elements leads to alpha thalassaemia syndrome. CONCLUSION Since many molecular markers are associated with the globin gene expression and switching over during the developmental stages, there is a need for increased awareness, new-born and prenatal screening program, especially for countries with high migration impact, and for improving the monitoring of patients with α-thalassaemia.
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Affiliation(s)
- Ibrahim Kalle Kwaifa
- Haematology Unit, Department of Pathology, Faculty of Medicine and Health Sciences, University Putra Malaysia (UPM), Serdang, Selangor, Malaysia
- Department of Haematology, School of Medical Laboratory Sciences, College of Health Sciences, Usmanu Danfodiyo University (UDU), Sokoto, North-Western, Nigeria
| | - Mei I Lai
- Haematology Unit, Department of Pathology, Faculty of Medicine and Health Sciences, University Putra Malaysia (UPM), Serdang, Selangor, Malaysia
- Genetics and Regenerative Medicine Research Centre, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia(UPM), Serdang, Selangor, Malaysia
| | - Sabariah Md Noor
- Haematology Unit, Department of Pathology, Faculty of Medicine and Health Sciences, University Putra Malaysia (UPM), Serdang, Selangor, Malaysia.
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Li J, Wang P, Li X, Wang Q, Zhang J, Lin Y. Cost-Utility Analysis of four Chelation Regimens for β-thalassemia Major: a Chinese Perspective. Mediterr J Hematol Infect Dis 2020; 12:e2020029. [PMID: 32395218 PMCID: PMC7202351 DOI: 10.4084/mjhid.2020.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/14/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The Iron chelation is essential to prevent iron overload damage of vital organs, like heart, liver, and endocrine glands, in patients with transfusion-dependent thalassemia. The most common chelation regimens for β-thalassemia major (β-TM) patients used in China are a combination therapy of deferoxamine and deferiprone (DFO+DFP), deferoxamine (DFO) monotherapy, deferiprone (DFP) monotherapy and deferasirox (DFX) monotherapy. Such patients use iron chelators their whole lives, resulting in enormous treatment costs. This study analyses the cost-utility of these four regimens from the Chinese healthcare system perspective. METHODS A Markov decision model was used over a 5-year time horizon and was populated using clinical data from a systematic literature review. We obtained utility data from local and previous research. Costs were estimated using Chinese national sources. RESULTS From the base-case analysis results, DFP was the most cost-effective chelation regimen, followed by DFO, DFX, and DFO+DFP. DFP had 97.32%, 99.43%, and 58.04% likelihood of being cost-effective versus DFX, DFO+DFP, and DFO, respectively, at a payment threshold of 193,932.00 CNY/QALY (QALY, quality-adjusted life-year). CONCLUSIONS DFP was the most cost-effective chelation regimen for β-TM patients, followed by DFO, DFX, and DFO+DFP. Using DFP as the primary treatment regimen may potentially result in cost-savings and QALY gains for the Chinese healthcare system. To increase these benefits, the Chinese government should take measures to lower DFX and DFO drug costs, and Chinese clinicians should choose the cheaper DFX and DFO, increase the utility of DFO+DFP and reduce mortality and morbidity of DFP. Changes in influential parameters easily affect the results of DFX versus DFO+DFP and of DFP versus DFO; clinicians should focus on such parameters and adjust the regimens accordingly.
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Affiliation(s)
- Jialian Li
- Department of Pharmacy, The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, Sichuan, China
| | - Peng Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, Sichuan, China
| | - Xue Li
- Department of Pharmacy, The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, Sichuan, China
| | - Qiaoyu Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, Sichuan, China
| | - Jiayou Zhang
- Department of Hematology, The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, Sichuan, China
| | - Yong Lin
- Department of Pharmacy, The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital, Chengdu, Sichuan, China
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Kashoor I, Batlle D. Proximal renal tubular acidosis with and without Fanconi syndrome. Kidney Res Clin Pract 2019; 38:267-281. [PMID: 31474092 PMCID: PMC6727890 DOI: 10.23876/j.krcp.19.056] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/13/2019] [Accepted: 06/19/2019] [Indexed: 01/02/2023] Open
Abstract
Proximal renal tubular acidosis (RTA) is caused by a defect in bicarbonate (HCO3−) reabsorption in the kidney proximal convoluted tubule. It usually manifests as normal anion-gap metabolic acidosis due to HCO3− wastage. In a normal kidney, the thick ascending limb of Henle’s loop and more distal nephron segments reclaim all of the HCO3− not absorbed by the proximal tubule. Bicarbonate wastage seen in type II RTA indicates that the proximal tubular defect is severe enough to overwhelm the capacity for HCO3− reabsorption beyond the proximal tubule. Proximal RTA can occur as an isolated syndrome or with other impairments in proximal tubular functions under the spectrum of Fanconi syndrome. Fanconi syndrome, which is characterized by a defect in proximal tubular reabsorption of glucose, amino acids, uric acid, phosphate, and HCO3−, can occur due to inherited or acquired causes. Primary inherited Fanconi syndrome is caused by a mutation in the sodium-phosphate cotransporter (NaPi-II) in the proximal tubule. Recent studies have identified new causes of Fanconi syndrome due to mutations in the EHHADH and the HNF4A genes. Fanconi syndrome can also be one of many manifestations of various inherited systemic diseases, such as cystinosis. Many of the acquired causes of Fanconi syndrome with or without proximal RTA are drug-induced, with the list of causative agents increasing as newer drugs are introduced for clinical use, mainly in the oncology field.
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Affiliation(s)
- Ibrahim Kashoor
- Division of Nephrology and Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Batlle
- Division of Nephrology and Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Holden P, Nair LS. Deferoxamine: An Angiogenic and Antioxidant Molecule for Tissue Regeneration. TISSUE ENGINEERING PART B-REVIEWS 2019; 25:461-470. [PMID: 31184273 DOI: 10.1089/ten.teb.2019.0111] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Deferoxamine (DFO) has been in use for half a century as a Food and Drug Administration-approved iron chelator, but recent studies indicate a variety of properties that could expand this drug's application into the fields of tissue and regenerative engineering. DFO has been implicated as an angiogenic agent in studies on ischemia, wound healing, and bone regeneration because of its ability to upregulate hypoxia-inducible factor-1 alpha (HIF-1α) and other key downstream angiogenic factors. DFO has also demonstrated antioxidant capabilities unrelated to its iron-chelating properties, making it a potential modulator of the oxidative stress involved in the inflammation response. Together, these properties make DFO a potential bioactive molecule to promote wound healing and enhance tissue integration of biomaterials in vivo. Impact Statement Deferoxamine (DFO) is approved by the Food and Drug Administration as an iron chelator and is been used to treat iron overload. Recent studies indicate that DFO may have important applications in the growing field of tissue regeneration because of its unique properties of downregulating inflammation while promoting vascularization, thereby enhancing wound healing in vivo.
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Affiliation(s)
- Paige Holden
- The Connecticut Convergence Institute for Translation in Regenerative Engineering, University of Connecticut Health Center, Farmington, Connecticut.,Department of Biomedical Engineering, University of Connecticut, Storrs, Connecticut
| | - Lakshmi S Nair
- The Connecticut Convergence Institute for Translation in Regenerative Engineering, University of Connecticut Health Center, Farmington, Connecticut.,Department of Biomedical Engineering, University of Connecticut, Storrs, Connecticut.,Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut.,Department of Material Science and Engineering, Institute of Material Science, University of Connecticut, Storrs, Connecticut
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Economic Evaluation of Chelation Regimens for β-Thalassemia Major: a Systematic Review. Mediterr J Hematol Infect Dis 2019; 11:e2019036. [PMID: 31308912 PMCID: PMC6613630 DOI: 10.4084/mjhid.2019.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/21/2019] [Indexed: 02/07/2023] Open
Abstract
Background Deferoxamine (DFO) or Deferiprone (DFP) or Deferasirox (DFX) monotherapy and DFO and DFP combination therapy (DFO+DFP) were four commonly implemented now chelation regimens for the iron overloaded of β-thalassemia major. This systematic review aims to determine the cost-effectiveness of four chelation regimens and provide evidence for the rational use of chelation regimens for β-thalassemia major therapy in the clinic. Methods A systematic literature search in MEDLINE, EMBASE, the Cochrane Library, China Biology Medicine, China National Knowledge Infrastructure, VIP Data, and WanFang Data was conducted in April 2018. In addition, a manual search was performed. Two researchers, working independently, selected the papers, extracted the data, and assessed the methodological quality of the included documents. Each included paper was evaluated using a checklist developed by Drummond et al. Results The number of records was initially 968, and eight papers met the final eligibility criteria. All the included eight papers were cost-utility analyses, and their methodological quality was fair. In these eight papers, nineteen studies were present. Nine studies of DFX versus DFO had contradictory results. Out of the nineteen studies, three studies of DFX versus DFP established that using DFP was cost-effective. Three studies of DFP versus DFO proved that using DFP was cost-effective. One survey of DFO+DFP versus DFO found that using DFO was cost-effective. One study of DFO+DFP versus DFP found that using DFP was cost-effective. Moreover, there were two studies of DFO+DFP versus DFX, but we cannot be sure which one of two chelation regimens was cost-effective. Conclusion In brief, DFP is cost-effective, followed by DFO or DFX, when an iron chelator is to be used alone for β-thalassemia iron overload treatment. All studies that compared DFO+DFP with DFO (or DFP) monotherapy established that the DFO+DFP was not cost-effective. Existing studies about DFO+DFP versus DFX could not prove which one of two chelation regimens was cost-effective. However, due to the low number of DFO+DFP versus DFO (or DFP or DFX) monotherapy studies, more extensive, high-quality research is required for further analysis and confirmation of our findings. Moreover, the cost-effectiveness is not an absolute issue when in different countries (regions) the results are opposite for other countries (regions). As a result, the local/national context had a substantial influence on the results of the pharmacoeconomic evaluation.
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Abstract
Iron overload cardiomyopathy (IOC) is a major cause of death in patients with diseases associated with chronic anemia such as thalassemia or sickle cell disease after chronic blood transfusions. Associated with iron overload conditions, there is excess free iron that enters cardiomyocytes through both L- and T-type calcium channels thereby resulting in increased reactive oxygen species being generated via Haber-Weiss and Fenton reactions. It is thought that an increase in reactive oxygen species contributes to high morbidity and mortality rates. Recent studies have, however, suggested that it is iron overload in mitochondria that contributes to cellular oxidative stress, mitochondrial damage, cardiac arrhythmias, as well as the development of cardiomyopathy. Iron chelators, antioxidants, and/or calcium channel blockers have been demonstrated to prevent and ameliorate cardiac dysfunction in animal models as well as in patients suffering from cardiac iron overload. Hence, either a mono-therapy or combination therapies with any of the aforementioned agents may serve as a novel treatment in iron-overload patients in the near future. In the present article, we review the mechanisms of cytosolic and/or mitochondrial iron load in the heart which may contribute synergistically or independently to the development of iron-associated cardiomyopathy. We also review available as well as potential future novel treatments.
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El-Beshlawy A, Inusa B, Beneitez Pastor D, Xicoy B, Soledada Duran Nieto M, Bruederle A, Azmon A, Gilotti G, Elalfy M. International sentinel site surveillance of patients with transfusional hemosiderosis treated with deferasirox in actual practice setting. ACTA ACUST UNITED AC 2019; 24:238-246. [PMID: 30558524 DOI: 10.1080/16078454.2018.1558758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The study evaluates the long-term deferasirox treatment of adult and pediatric patients with chronic transfusional iron overload in clinical practice. METHODS In this non-interventional study, patients were observed for up to 3 years from initiation of deferasirox treatment both prospectively and retrospectively for up to 1 year prior to enrollment. The primary end points were the proportion of patients with ≥1 notable increase in serum creatinine (SCr), and ≥1 notable increase in alanine aminotransferase (ALT). RESULTS Overall, 120 patients were enrolled and 51 completed the study, with a limited 3-year dropout rate of 12.5% due to adverse events (AEs). Increase in SCr > 33% above baseline and the age-adjusted ULN (upper limit of normal) was observed in 14 patients (95%CI, 7.1-19.2). The ALT levels >5 × ULN was observed in 1 patient. Most frequent AEs reported during treatment with deferasirox include gastrointestinal disturbances. CONCLUSIONS The long-term treatment with deferasirox was manageable in most transfusion-dependent patients with no unexpected safety findings. Regular monitoring and an adjusted deferasirox dosing strategy per local labels allowed continued iron chelation treatment and control of transfusional iron in the majority of patients on study.
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Affiliation(s)
| | - Baba Inusa
- b Evelina Children's Hospital, Guy's and St Thomas' Hospital NHS Trust , London , UK
| | | | - Blanca Xicoy
- d ICO-Badalona-Hospital Germans Trias i Pujol, Josep Carreras Leukemia Research Institute , Barcelona , Spain
| | | | | | - Amin Azmon
- f Novartis Pharma AG , Basel , Switzerland
| | - Geralyn Gilotti
- g Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
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Salimi A, Sharif Makhmal Zadeh B, Kazemi M. Preparation and optimization of polymeric micelles as an oral drug delivery system for deferoxamine mesylate: in vitro and ex vivo studies. Res Pharm Sci 2019; 14:293-307. [PMID: 31516506 PMCID: PMC6714110 DOI: 10.4103/1735-5362.263554] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Deferoxamine mesylate (DFO) is administered as a slow subcutaneous or intravenous infusion due to its poor oral bioavailability and lack of dose proportionality. The aim of the present study was to prepare and optimize polymeric micelles containing DFO, as an oral drug delivery system for increasing permeability and oral bioavailability. Based on a full factorial design with three variables in two levels, eight polymeric micelle formulations were made using film hydration method. Two polymers including 0.1% of carbomer 934 and Poloxamer®P 407 and two blends of surfactant + co-surfactant including 1 and 2 fold of critical micelle concentration of Labrafil® + Labrasol® and Tween 80 + Span 20 were used to prepare polymeric micelles. The effect of variables on particle size (PS), entrapment efficiency (EE), drug release, thermal behavior, in vitro iron bonding and ex vivo rat intestinal permeability were evaluated. The PS of polymeric micelles was less than 83 nm that showed 80% EE with continuous drug release pattern. The change in type of polymer from carbomer to Ploxamer® significantly increased drug release. All polymeric micelles increased the iron-bonding ability of DFO compared to control. This could be due to surfactants that can play an important role in this ability. Polymeric micelles increased drug permeability through intestine more than 2.5 folds compared to control mainly affected by polymer type. Optimized polymeric micelle consists of Tween 80 and Span 20 with 1.35 folds of critical micelle concentration and Poloxamer® demonstrated 97.32% iron bonding and a 3-fold increase in permeation through the rat intestine compared with control.
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Affiliation(s)
- Anayatollah Salimi
- School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, I.R. Iran.,Nanotechnology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, I.R. Iran
| | - Behzad Sharif Makhmal Zadeh
- School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, I.R. Iran.,Nanotechnology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, I.R. Iran
| | - Moloud Kazemi
- School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, I.R. Iran
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Antmen B, Karakaş Z, Yeşilipek MA, Küpesiz OA, Şaşmaz İ, Uygun V, Kurtoğlu E, Oktay G, Aydogan G, Akın M, Salcioglu Z, Vergin C, Kazancı EG, Ünal S, Çalışkan Ü, Aral YZ, Türkkan E, Meral Güneş A, Tunç B, Gümrük F, Ayhan AC, Söker M, Koç A, Oymak Y, Ertem M, Timur Ç, Yıldırmak Y, İrken G, Apak H, Biner B, Eren TG, Işık Balcı Y, Koçak Ü, Karasu G, Akkaynak D, Patıroğlu T. Deferasirox in children with transfusion‐dependent thalassemia or sickle cell anemia: A large cohort real‐life experience from Turkey (REACH‐THEM). Eur J Haematol 2018; 102:123-130. [DOI: 10.1111/ejh.13180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 01/01/2023]
Affiliation(s)
| | | | | | | | - İlgen Şaşmaz
- Çukurova University Medical Faculty Adana Turkey
| | - Vedat Uygun
- Antalya Training and Research Hospital Antalya Turkey
| | | | | | - Gonul Aydogan
- Kanuni Sultan Suleyman Training and Research Hospital Istanbul Turkey
| | | | - Zafer Salcioglu
- Kanuni Sultan Suleyman Training and Research Hospital Istanbul Turkey
| | - Canan Vergin
- Dr. Behcet Uz Child Disease and Surgery Training and Research Hospital Izmir Turkey
| | | | - Selma Ünal
- Mersin University Medical Faculty Mersin Turkey
| | - Ümran Çalışkan
- Necmettin Erbakan University Meram Medical Faculty Konya Turkey
| | | | - Emine Türkkan
- Okmeydanı Training and Research Hospital Istanbul Turkey
| | | | - Bahattin Tunç
- Ankara Child Health and Disease, Hematology Oncology Training and Research Hospital Ankara Turkey
| | - Fatma Gümrük
- Hacettepe University Medical Faculty Ankara Turkey
| | | | - Murat Söker
- Dicle University Medical Faculty Diyarbakır Turkey
| | - Ahmet Koç
- Harran University Medical Faculty Şanlıurfa Turkey
| | - Yeşim Oymak
- Harran University Medical Faculty Şanlıurfa Turkey
| | - Mehmet Ertem
- Faculty of Medicine Ankara University Ankara Turkey
| | - Çetin Timur
- Goztepe Training and Research Hospital Istanbul Turkey
| | | | | | - Hilmi Apak
- Istanbul University Cerrahpasa Medical Faculty Istanbul Turkey
| | - Betül Biner
- Trakya University Medical Faculty Edirne Turkey
| | | | | | - Ülker Koçak
- Gazi University Medical Faculty Ankara Turkey
| | - Gülsün Karasu
- Istanbul Zeynep Kamil Women and Children's Diseases raining and Research Hospital Istanbul Turkey
| | - Diyar Akkaynak
- Novartis Saglık, Gıda ve Tarım Ürünleri San. ve Tic. A.S Istanbul Turkey
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Taher AT, Origa R, Perrotta S, Kouraklis A, Ruffo GB, Kattamis A, Goh AS, Huang V, Zia A, Herranz RM, Porter JB. Patient-reported outcomes from a randomized phase II study of the deferasirox film-coated tablet in patients with transfusion-dependent anemias. Health Qual Life Outcomes 2018; 16:216. [PMID: 30453981 PMCID: PMC6245526 DOI: 10.1186/s12955-018-1041-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/31/2018] [Indexed: 11/05/2023] Open
Abstract
BACKGROUND Adherence to long-term chelation therapy in transfusion-dependent patients is critical to prevent iron overload-related complications. Once-daily deferasirox dispersible tablets (DT) have proven long-term efficacy and safety in patients ≥2 years old with chronic transfusional iron overload. However, barriers to optimal adherence remain, including palatability, preparation time, and requirements for fasting state. A new film-coated tablet (FCT) formulation was developed, swallowed once daily (whole/crushed) with/without a light meal. METHODS The open-label, Phase II ECLIPSE study evaluated patient-reported outcomes (PROs) in transfusion-dependent thalassemia or lower-risk myelodysplastic syndromes patients randomized 1:1 to receive deferasirox DT or FCT over 24 weeks as a secondary outcome of the study. Three PRO questionnaires were developed to evaluate both deferasirox formulations: 1) Modified Satisfaction with Iron Chelation Therapy Questionnaire; 2) Palatability Questionnaire; 3) Gastrointestinal (GI) Symptom Diary. RESULTS One hundred seventy three patients were enrolled; 87 received the FCT and 86 the DT formulation. FCT recipients consistently reported better adherence (easier to take medication, less bothered by time to prepare medication and waiting time before eating), greater satisfaction/preference (general satisfaction and with administration of medicine), and fewer concerns (less worry about not swallowing enough medication, fewer limitations in daily activities, less concern about side effects). FCT recipients reported no taste or aftertaste and could swallow all their medicine with an acceptable amount of liquid. GI summary scores were low for both formulations. CONCLUSIONS These findings suggest a preference in favor of the deferasirox FCT formulation regardless of underlying disease or age group. Better patient satisfaction and adherence to chelation therapy may reduce iron overload-related complications. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02125877; registered April 26, 2014.
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Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, Director - Fellowship and Residents Research Program, Faculty of Medicine American University of Beirut Medical Center, Beirut, Lebanon.
- Emory School of Medicine, Atlanta, USA.
| | - Raffaella Origa
- Ospedale Pediatrico Microcitemico 'A.Cao', A.O. 'G. Brotzu', Cagliari, Italy
| | | | - Alexandra Kouraklis
- Hematology Division, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Giovan Battista Ruffo
- U.O.C. Ematolog. Con Talassemia, A.O. Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Antonis Kattamis
- First Department of Pediatrics, University of Athens, Athens, Greece
| | - Ai-Sim Goh
- Department of Medicine, Hospital Pulau Pinang, Georgetown, Penang, Malaysia
| | - Vicky Huang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Cheng WY, Said Q, Hao Y, Xiao Y, Vekeman F, Bobbili P, Duh MS, Nandal S, Blinder M. Adherence to iron chelation therapy in patients who switched from deferasirox dispersible tablets to deferasirox film-coated tablets. Curr Med Res Opin 2018; 34:1959-1966. [PMID: 29701080 DOI: 10.1080/03007995.2018.1470500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare real-world adherence to and persistence with deferasirox film-coated tablets (DFX-FCT) and deferasirox dispersible tablets (DFX-DT) among patients who switched from DFX-DT to DFX-FCT, overall and by disease type (sickle cell disease [SCD], thalassemia, and myelodysplastic syndrome [MDS]). METHODS Patients were ≥2 years old and had ≥2 DFX-FCT claims over the study period and ≥2 DFX-DT claims before the index date (first DFX-FCT claim). The DFX-DT period was defined from the first DFX-DT claim to the index date; the DFX-FCT period was defined from the index date to the end of the study period. Adherence was measured as medication possession ratio (MPR) and proportion of days covered (PDC). Persistence was defined as continuous medication use without a gap ≥30 or 60 days between refills. Comparisons were conducted using paired-sample Wilcoxon sign-rank and McNemar's tests. RESULTS In total, 606 patients were selected (SCD: 348; thalassemia: 107; MDS: 106; other: 45). Adherence and persistence in the DFX-FCT vs DFX-DT period was significantly higher across all measures: mean MPR was 0.80 vs 0.76 (p < .001); 60.9% vs 54.3% of patients had MPR ≥ 0.8 (p = .009); mean 3-month PDC was 0.83 vs 0.71 (p < .001); 64.2% vs 45.4% of patients had 3-month PDC ≥ 0.8 (p < .001); 87.2% vs 63.4% of patients had 3-month persistence with no gap ≥30 days and 96.1% vs 79.9% with no gap ≥60 days (p < .001). Adherence and persistence improved after switching across all diseases, particularly MDS. CONCLUSIONS Adherence and persistence improved significantly after switching from DFX-DT to DFX-FCT for all diseases, but especially MDS.
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Affiliation(s)
| | - Qayyim Said
- b Novartis Pharmaceutical Corporation , East Hanover , NJ , USA
| | - Yanni Hao
- b Novartis Pharmaceutical Corporation , East Hanover , NJ , USA
| | | | | | | | | | - Savita Nandal
- b Novartis Pharmaceutical Corporation , East Hanover , NJ , USA
| | - Morey Blinder
- c Washington University School of Medicine , St. Louis , MO , USA
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Deferasirox: Over a Decade of Experience in Thalassemia. Mediterr J Hematol Infect Dis 2018; 10:e2018066. [PMID: 30416698 PMCID: PMC6223547 DOI: 10.4084/mjhid.2018.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 09/15/2018] [Indexed: 01/19/2023] Open
Abstract
Thalassemia incorporates a broad clinical spectrum characterized by decreased or absent production of normal hemoglobin leading to decreased red blood cell survival and ineffective erythropoiesis. Chronic iron overload remains an inevitable complication resulting from regular blood transfusions (transfusion-dependent) and/or increased iron absorption (mainly non-transfusion-dependent thalassemia), requiring adequate treatment to prevent the significant associated morbidity and mortality. Iron chelation therapy has become a cornerstone in the management of thalassemia patients, leading to improvements in their outcome and quality of life. Deferasirox (DFX), an oral iron chelating agent, is approved for use in transfusion dependent and non-transfusion-dependent thalassemia and has shown excellent efficacy in this setting. We herein present an updated review of the role of deferasirox in thalassemia, exploring over a decade of experience, which has documented its effectiveness and convenience; in addition to its manageable safety profile.
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Kattamis A, Aydinok Y, Taher A. Optimising management of deferasirox therapy for patients with transfusion-dependent thalassaemia and lower-risk myelodysplastic syndromes. Eur J Haematol 2018; 101:272-282. [PMID: 29904950 DOI: 10.1111/ejh.13111] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2018] [Indexed: 01/19/2023]
Abstract
Effective iron chelation therapy is an important part of treatment in patients with transfusion-dependent thalassaemia and lower-risk myelodysplastic syndromes (MDS). Key strategies for optimising iron chelation therapy include ensuring good adherence and preventing and managing adverse events (AEs). Good adherence to iron chelation therapy with deferoxamine and deferasirox has been linked to improved survival and/or reductions in complications related to iron overload; however, maintaining good adherence to iron chelators can be challenging. Patients with transfusion-dependent thalassaemia or lower-risk MDS showed better adherence to the deferasirox film-coated tablet (FCT) formulation than to the deferasirox dispersible tablet formulation in the ECLIPSE trial, reflecting in part the improved palatability and convenience of deferasirox FCT. As well as affecting adherence, AEs may lead to dose reduction, interruption or discontinuation, resulting in suboptimal iron chelation therapy. Preventing and successfully managing AEs may help limit their impact on adherence, and following dosage and administration recommendations for iron chelators such as deferasirox may help minimise AEs and optimise treatment in patients with transfusion-dependent thalassaemia and lower-risk MDS.
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Affiliation(s)
- Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Yesim Aydinok
- Department of Pediatric Hematology, Ege University Hospital, Izmir, Turkey
| | - Ali Taher
- Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
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A paradigm shift on beta-thalassaemia treatment: How will we manage this old disease with new therapies? Blood Rev 2018; 32:300-311. [DOI: 10.1016/j.blre.2018.02.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/05/2018] [Accepted: 02/09/2018] [Indexed: 01/19/2023]
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Özbolat G, Yegani AA, Tuli A. Synthesis, characterization and electrochemistry studies of iron(III) complex with curcumin ligand. Clin Exp Pharmacol Physiol 2018; 45:1221-1226. [DOI: 10.1111/1440-1681.12964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/27/2018] [Accepted: 05/02/2018] [Indexed: 01/25/2023]
Affiliation(s)
- Gülüzar Özbolat
- Department of Biochemistry; Faculty of Medicine; Cukurova University; Adana Turkey
| | - Arash Alizadeh Yegani
- Department of Pharmacology; Faculty of Veterinary; Mustafa Kemal University; Hatay Turkey
| | - Abdullah Tuli
- Department of Biochemistry; Faculty of Medicine; Cukurova University; Adana Turkey
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Bou-Fakhredin R, Elias J, Taher AT. Iron Overload and Chelation Therapy in Hemoglobinopathies. THALASSEMIA REPORTS 2018. [DOI: 10.4081/thal.2018.7478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Iron overload (IOL) is highly prevalent among patients with hemoglobinopathies; both transfusion dependent thalassemia (TDT) and non-transfusion dependent thalassemia (NTDT). Whether IOL is secondary to regular transfusions like in TDT, or develops from increased intestinal absorption like in NTDT, it can cause significant morbidity and mortality. In TDT patients, iron accumulation in organ tissues is highly evident, and leads to organ toxicity and dysfunction. IOL in NTDT patients is cumulative with advancing age, and concern with secondary morbidity starts beyond the age of 10 years, as shown by the OPTIMAL CARE study. Several modalities are available for the diagnosis and monitoring of IOL. Serum ferritin (SF) assessment is widely available and heavily relied on in resource-poor countries. Non-invasive iron monitoring using MRI has become the gold standard to diagnose IOL. Three iron chelators are currently available for the treatment of IOL: deferoxamine (DFO) in subcutaneous or intravenous injection, oral deferiprone (DFP) in tablet or solution form, and oral deferasirox (DFX) in dispersible tablet (DT) and film-coated tablet (FCT). Today, the goal of ICT is to maintain safe levels of body iron at all times. Appropriate tailoring ICT with chelator choices and dose adjustment must be implemented in a timely manner. Clinical decision to initiate, adjust and stop ICT is based on SF, MRI-LIC and cardiac T2*. In this article, we review the mechanism of IOL in both TDT and NTDT, the pathophysiology behind it, its complications, and the different ways to assess and quantify it. We will also discuss the different ICT modalities available, and the emergence of novel therapies.
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Renal iron deposition by magnetic resonance imaging in pediatric β-thalassemia major patients: Relation to renal biomarkers, total body iron and chelation therapy. Eur J Radiol 2018; 103:65-70. [PMID: 29803388 DOI: 10.1016/j.ejrad.2018.04.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 04/03/2018] [Accepted: 04/06/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The reciprocal of multiecho gradient-echo (ME-GRE) T2* magnetic resonance imaging (MRI) R2*, rises linearly with tissue iron concentration in both heart and liver. Little is known about renal iron deposition in β-thalassemia major (β-TM). AIM To assess renal iron overload by MRI and its relation to total body iron and renal function among 50 pediatric patients with β-TM. METHODS Serum ferritin, serum cystatin C, urinary albumin creatinine ratio (UACR), and urinary β2-microglobulin (β2 M) were measured with calculation of β2 M/albumin ratio. Quantification of liver, heart and kidney iron overload was done by MRI. RESULTS Serum cystatin C, UACR and urinary β2 microglobulin as well as urinary β2m/albumin were significantly higher in β-TM patients than the control group. No significant difference was found as regards renal R2* between Patients with mean serum ferritin above 2500 μg/L and those with lower serum cutoff. Renal R2* was higher in patients with poor compliance to chelation therapy and positively correlated to indirect bilirubin, LDH, cystatin C and LIC but inversely correlated to cardiac T2*. CONCLUSION kidney iron deposition impairs renal glomerular and tubular functions in pediatric patients with β-TM and is related to hemolysis, total body iron overload and poor compliance to chelation.
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Abstract
BACKGROUND β-thalassemia major (BTM) is an inherited blood disorder leading to severe anemia. A better understanding of BTM complications can be considered an important factor in developing effective health care provision. METHOD A descriptive exploratory design was used to identify the clinical burden of BTM from affected children's perspective. A convenience sample of 45 patients with BTM, accompanied by a family member, was recruited from a governmental hospital during April-May 2015. RESULTS The most reported clinical burden was facial deformity 86.9%, followed by systematic infection (48.8%), growth delay (44.4%), and liver problems (39.9%). Patient age was significantly associated with clinical burdens such as bone pain and facial deformity. The number of blood transfusions received was associated with growth delay and bone pain. CONCLUSION This study highlights the clinical burdens of thalassemia on affected children, in terms of physical appearance, growth delay and other burdens.
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Vosper J, Evangeli M, Porter JB, Shah F. Psychological Factors Associated with Episodic Chelation Adherence in Thalassemia. Hemoglobin 2018. [PMID: 29521137 DOI: 10.1080/03630269.2018.1433686] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
β-Thalassemia major (β-TM) is a life-long genetic hemoglobin (Hb) disorder requiring intensive treatment regimens, including frequent blood transfusions and daily chelation therapy. Understanding psychosocial correlates of chelation adherence is important for developing interventions to improve adherence. This study investigated within-participant correlates of oral chelation adherence on a daily (episodic) basis. Thirty-seven adult participants with β-TM were recruited from clinics at two hospitals (22 males, 9 females, mean age 34.5 years, range 19-54 years). A structured interview was used to assess behavioral and psychological situational variables related to an adherent and a nonadherent episode for each participant. Positive outcome expectancies and higher self-efficacy were both significantly associated with adherent episodes. Behavioral variables, including difficulty in accessing medication, location, and whether alone or with others, were also associated with nonadherent episodes. Findings suggested that situational psychological factors are important for chelation adherence. Adherence interventions should consider focusing on potentially modifiable situational variables (psychological and behavioral).
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Affiliation(s)
- Jane Vosper
- a Department of Clinical Psychology , Royal Holloway University of London , Egham , UK
| | - Michael Evangeli
- a Department of Clinical Psychology , Royal Holloway University of London , Egham , UK
| | - John B Porter
- b Clinical Haematology, Joint Red Cell Unit , University College London Hospitals , London , UK
| | - Farrukh Shah
- c Clinical Haematology, Joint Red Cell Unit, Department of Haematology , The Whittington Hospital , London , UK
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Abstract
Introduction of MRI techniques for identifying and monitoring tissue iron overload and the current understanding of iron homeostasis in transfusion-dependent (TDT) and non-transfusion-dependent thalassemia have allowed for a more robust administration of iron chelation therapies. The development of safe and efficient oral iron chelators and the insights gained from large-scale prospective studies using these agents have improved iron overload management. A significant reduction in iron toxicity-induced morbidity and mortality and improvements in quality of life were observed in TDT. The appropriate management of tissue-specific iron loading in TDT has been portrayed using evidence-based data obtained from investigational studies.
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Affiliation(s)
- Yesim Aydinok
- Department of Pediatric Hematology and Oncology, Ege University Children's Hospital, Bornova, Izmir 35100, Turkey.
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45
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Abstract
Inherited haemoglobin disorders, including thalassaemia and sickle-cell disease, are the most common monogenic diseases worldwide. Several clinical forms of α-thalassaemia and β-thalassaemia, including the co-inheritance of β-thalassaemia with haemoglobin E resulting in haemoglobin E/β-thalassaemia, have been described. The disease hallmarks include imbalance in the α/β-globin chain ratio, ineffective erythropoiesis, chronic haemolytic anaemia, compensatory haemopoietic expansion, hypercoagulability, and increased intestinal iron absorption. The complications of iron overload, arising from transfusions that represent the basis of disease management in most patients with severe thalassaemia, might further complicate the clinical phenotype. These pathophysiological mechanisms lead to an array of clinical manifestations involving numerous organ systems. Conventional management primarily relies on transfusion and iron-chelation therapy, as well as splenectomy in specific cases. An increased understanding of the molecular and pathogenic factors that govern the disease process have suggested routes for the development of new therapeutic approaches that address the underlying chain imbalance, ineffective erythropoiesis, and iron dysregulation, with several agents being evaluated in preclinical models and clinical trials.
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Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon.
| | - David J Weatherall
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, IRCCS Ca'Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
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Bou-Fakhredin R, Bazarbachi AH, Chaya B, Sleiman J, Cappellini MD, Taher AT. Iron Overload and Chelation Therapy in Non-Transfusion Dependent Thalassemia. Int J Mol Sci 2017; 18:ijms18122778. [PMID: 29261151 PMCID: PMC5751376 DOI: 10.3390/ijms18122778] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 12/17/2017] [Accepted: 12/20/2017] [Indexed: 01/19/2023] Open
Abstract
Iron overload (IOL) due to increased intestinal iron absorption constitutes a major clinical problem in patients with non-transfusion-dependent thalassemia (NTDT), which is a cumulative process with advancing age. Current models for iron metabolism in patients with NTDT suggest that suppression of serum hepcidin leads to an increase in iron absorption and subsequent release of iron from the reticuloendothelial system, leading to depletion of macrophage iron, relatively low levels of serum ferritin, and liver iron loading. The consequences of IOL in patients with NTDT are multiple and multifactorial. Accurate and reliable methods of diagnosis and monitoring of body iron levels are essential, and the method of choice for measuring iron accumulation will depend on the patient's needs and on the available facilities. Iron chelation therapy (ICT) remains the backbone of NTDT management and is one of the most effective and practical ways of decreasing morbidity and mortality. The aim of this review is to describe the mechanism of IOL in NTDT, and the clinical complications that can develop as a result, in addition to the current and future therapeutic options available for the management of IOL in NTDT.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
| | - Abdul-Hamid Bazarbachi
- Faculty of Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
| | - Bachar Chaya
- Faculty of Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
| | - Joseph Sleiman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
| | - Maria Domenica Cappellini
- Department of Medicine, Ca'Granda Foundation IRCCS, University of Milan, Milan 20122, Italy.
- Department of Clinical Science and Community, University of Milan, Milan 20122, Italy.
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut 11-0236, Lebanon.
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Taher AT, Saliba AN. Iron overload in thalassemia: different organs at different rates. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:265-271. [PMID: 29222265 PMCID: PMC6142532 DOI: 10.1182/asheducation-2017.1.265] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Thalassemic disorders lie on a phenotypic spectrum of clinical severity that depends on the severity of the globin gene mutation and coinheritance of other genetic determinants. Iron overload is associated with increased morbidity in both patients with transfusion-dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT). The predominant mechanisms driving the process of iron loading include increased iron burden secondary to transfusion therapy in TDT and enhanced intestinal absorption secondary to ineffective erythropoiesis and hepcidin suppression in NTDT. Different organs are affected differently by iron overload in TDT and NTDT owing to the underlying iron loading mechanism and rate of iron accumulation. Serum ferritin measurement and noninvasive imaging techniques are available to diagnose iron overload, quantify its extent in different organs, and monitor clinical response to therapy. This chapter discusses the general approach to iron chelation therapy based on organ involvement using the available iron chelators: deferoxamine, deferiprone, and deferasirox. Other novel experimental options for treatment and prevention of complications associated with iron overload in thalassemia are briefly discussed.
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Affiliation(s)
- Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; and
| | - Antoine N. Saliba
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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Algiraigri AH, Kassam A. Hydroxyurea for hemoglobin E/β-thalassemia: a systematic review and meta-analysis. Int J Hematol 2017; 106:748-756. [PMID: 28786080 DOI: 10.1007/s12185-017-2307-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/24/2022]
Abstract
Hemoglobin E-beta thalassemia (Hb E/β-thalassemia) is a distinct, yet common, type of β-thalassemia, in which the patient co-inherits a β-thalassemia allele from one parent, and a structural variant, Hb E, from the other parent. This co-inheritance leads to remarkable clinical heterogeneity, varying degrees of chronic anemia, and a wide spectrum of complications due to ineffective erythropoiesis and iron overload. Hydroxyurea (HU), an oral chemotherapeutic drug, is expected to decrease disease severity. To assess the clinical efficacy and safety of HU in Hb E/β-thalassemia patients. We searched MEDLINE, EMBASE, Cochrane databases, and major preceding conferences for studies that assessed HU in Hb E/β-thalassemias patients. The effect size was estimated as a proportion (responder/sample size). Qualities of eligible studies were assessed using NIH tools. A total of five [one randomized clinical trial (RCT) and four observational] studies involving 106 patients were included. HU was associated with a significant RR of 46% with no statistical heterogeneity. No serious adverse effects were reported. Patients with Hb E/β-thalassemia may benefit from a trial of HU, though large RCTs assessing efficacy should be conducted to confirm the findings of this meta-analysis and to assess long-term toxicity and response sustainability.
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Affiliation(s)
- Ali H Algiraigri
- Department of Hematology, King Abdulaziz University Hospital, Jeddah, 22252, Saudi Arabia. .,King Faisal Special Hospital and Research Center, Jeddah, Saudi Arabia. .,Department of Community Health Science, University of Calgary, Calgary, AB, Canada.
| | - Aliya Kassam
- Department of Community Health Science, University of Calgary, Calgary, AB, Canada
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Horodniceanu EG, Bal V, Dhatt H, Carter JA, Huang V, Lasch K. Qualitative modification and development of patient- and caregiver-reported outcome measures for iron chelation therapy. Health Qual Life Outcomes 2017; 15:129. [PMID: 28645270 PMCID: PMC5481883 DOI: 10.1186/s12955-017-0702-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 06/06/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Compliance, palatability, gastrointestinal (GI) symptom, and treatment satisfaction patient- and observer-reported outcome (PRO, ObsRO) measures were developed/modified for patients with transfusion-dependent anemias or myelodysplastic syndrome (MDS) requiring iron chelation therapy (ICT). METHODS This qualitative cross-sectional observational study used grounded theory data collection and analysis methods and followed PRO/ObsRO development industry guidance. Patients and caregivers of patients with transfusion-dependent anemias or MDS were individually interviewed face-to-face to cognitively debrief the Compliance, Palatability, GI Symptom Diary, and Modified Satisfaction with Iron Chelation Therapy (SICT) instruments presented electronically. Interviews were conducted in sets. Interviews began open-endedly to spontaneously elicit ICT experiences. Item modifications were debriefed during the later interviews. Interviews were audio recorded, transcribed, and coded. Data was analyzed using ATLAS.ti qualitative research software. RESULTS Twenty-one interviews were completed (Set 1: 5 patients, 6 caregivers; Set 2: 6 patients, 4 caregivers) in 6 US cities. Mean age was 43 years for patients and 9 years for children of caregivers. Conditions requiring ICT use across groups included transfusion-dependent anemias (85.7%) and MDS (14.3%). Concepts spontaneously reported were consistent with instruments debriefed. Interview analysis resulted in PRO and ObsRO versions of each instrument: Compliance (2 items), Palatability (4 items), GI Symptom Diary (6 items), and Modified SICT (PRO = 13, ObsRO = 17 items). CONCLUSION Qualitative research data from cognitive interviews supports the content validity and relevance of the instruments developed/modified. Quantitative validation of these PRO and ObsRO measures is needed testing for validity, reliability, and responsiveness for future research use with new formulations of oral ICT.
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Affiliation(s)
| | - Vasudha Bal
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ 07936 USA
| | - Harman Dhatt
- Pharmerit International, 4350 East West Highway, Suite 1110, Bethesda, MD 20814 USA
| | - John A. Carter
- Pharmerit International, 4350 East West Highway, Suite 1110, Bethesda, MD 20814 USA
| | - Vicky Huang
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ 07936 USA
| | - Kathryn Lasch
- Pharmerit International, 300 Washington Street, Suite 410, Newton, MA 02458 USA
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Shah NR. Advances in iron chelation therapy: transitioning to a new oral formulation. Drugs Context 2017; 6:212502. [PMID: 28706555 PMCID: PMC5499896 DOI: 10.7573/dic.212502] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 05/02/2017] [Indexed: 01/19/2023] Open
Abstract
Iron overload is a concern for patients who require repeated red-blood-cell transfusions due to conditions such as sickle cell disease, thalassemia, or myelodysplastic syndromes. The recommended treatment for removing excess iron in these patients is iron chelation therapy. Currently available iron chelators include deferoxamine, which is administered by injection, and deferasirox and deferiprone, both of which are administered orally. Adherence to iron chelator therapy is an important consideration and may be affected by side effects. A new formulation of deferasirox, a film-coated tablet (FCT), has the potential to improve adherence by offering greater flexibility in administration compared with the original formulation of deferasirox, a dispersible tablet (DT) for oral suspension. This review provides an overview of the currently available iron chelator formulations, with a focus on a comparison between deferasirox DT for oral suspension and deferasirox FCT. The new formulation may be associated with fewer side effects and has increased bioavailability. In addition, alternative strategies for iron chelation, such as combining two different iron chelators, will be discussed.
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