1
|
Yampayon K, Anantachoti P, Chongmelaxme B, Yodsurang V. Genetic polymorphisms influencing deferasirox pharmacokinetics, efficacy, and adverse drug reactions: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1069854. [PMID: 37261288 PMCID: PMC10227503 DOI: 10.3389/fphar.2023.1069854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 05/02/2023] [Indexed: 06/02/2023] Open
Abstract
Objective: Deferasirox is an iron-chelating agent prescribed to patients with iron overload. Due to the interindividual variability of deferasirox responses reported in various populations, this study aims to determine the genetic polymorphisms that influence drug responses. Methods: A systematic search was performed from inception to March 2022 on electronic databases. All studies investigating genetic associations of deferasirox in humans were included, and the outcomes of interest included pharmacokinetics, efficacy, and adverse drug reactions. Fixed- and random-effects model meta-analyses using the ratio of means (ROM) were performed. Results: Seven studies involving 367 participants were included in a meta-analysis. The results showed that subjects carrying the A allele (AG/AA) of ABCC2 rs2273697 had a 1.23-fold increase in deferasirox Cmax (ROM = 1.23; 95% confidence interval [CI]:1.06-1.43; p = 0.007) and a lower Vd (ROM = 0.48; 95% CI: 0.36-0.63; p < 0.00001), compared to those with GG. A significant attenuated area under the curve of deferasirox was observed in the subjects with UGT1A3 rs3806596 AG/GG by 1.28-fold (ROM = 0.78; 95% CI: 0.60-0.99; p = 0.04). In addition, two SNPs of CYP24A1 were also associated with the decreased Ctrough: rs2248359 CC (ROM = 0.50; 95% CI: 0.29-0.87; p = 0.01) and rs2585428 GG (ROM = 0.47; 95% CI: 0.35-0.63; p < 0.00001). Only rs2248359 CC was associated with decreased Cmin (ROM = 0.26; 95% CI: 0.08-0.93; p = 0.04), while rs2585428 GG was associated with a shorter half-life (ROM = 0.44; 95% CI: 0.23-0.83; p = 0.01). Conclusion: This research summarizes the current evidence supporting the influence of variations in genes involved with drug transporters, drug-metabolizing enzymes, and vitamin D metabolism on deferasirox responses.
Collapse
Affiliation(s)
- Kittika Yampayon
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Puree Anantachoti
- Social and Administrative Pharmacy Department, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Bunchai Chongmelaxme
- Social and Administrative Pharmacy Department, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Varalee Yodsurang
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
- Preclinical Toxicity and Efficacy, Assessment of Medicines and Chemicals Research Unit, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
2
|
Stempel JM, Podoltsev NA, Dosani T. Supportive Care for Patients With Myelodysplastic Syndromes. Cancer J 2023; 29:168-178. [PMID: 37195773 DOI: 10.1097/ppo.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Myelodysplastic syndromes are a heterogeneous group of bone marrow disorders characterized by ineffective hematopoiesis, progressive cytopenias, and an innate capability of progressing to acute myeloid leukemia. The most common causes of morbidity and mortality are complications related to myelodysplastic syndromes rather than progression to acute myeloid leukemia. Although supportive care measures are applicable to all patients with myelodysplastic syndromes, they are especially essential in patients with lower-risk disease who have a better prognosis compared with their higher-risk counterparts and require longer-term monitoring of disease and treatment-related complications. In this review, we will address the most frequent complications and supportive care interventions used in patients with myelodysplastic syndromes, including transfusion support, management of iron overload, antimicrobial prophylaxis, important considerations in the era of COVID-19 (coronavirus infectious disease 2019), role of routine immunizations, and palliative care in the myelodysplastic syndrome population.
Collapse
|
3
|
Shah FT, Porter JB, Sadasivam N, Kaya B, Moon JC, Velangi M, Ako E, Pancham S. Guidelines for the monitoring and management of iron overload in patients with haemoglobinopathies and rare anaemias. Br J Haematol 2022; 196:336-350. [PMID: 34617272 DOI: 10.1111/bjh.17839] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/10/2021] [Accepted: 09/02/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Farrukh T Shah
- Department of Haematology, Whittington Health, London, UK
| | - John B Porter
- Department of Haematology, University College Hospitals, London, UK
| | - Nandini Sadasivam
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Banu Kaya
- Department of Paediatric Haematology and Oncology, Barts Health NHS Trust, London, UK
| | - James C Moon
- Department of Cardiovascular Imaging, Barts Heart Centre, St Bartholomew's Hospital, London, UK
- Institutes for Cardiovascular Science, University College London, London, UK
| | - Mark Velangi
- Department of Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Emmanuel Ako
- Department of Cardiology, Chelsea and Westminster Hospital, London, UK
| | - Shivan Pancham
- Department of Haematology, Sandwell and West Birmingham NHS Trust, West Bromwich, UK
| |
Collapse
|
4
|
Marini V, Pinto VM, Stella M, Fucile C, Lantieri F, Luci G, Gianesin B, Bacigalupo L, Forni GL, Mattioli F. Effect of Aging on Deferasirox Therapy in Transfusion-dependent Patients. A Prospective- Retrospective, Cohort-study. Curr Drug Metab 2022; 23:1072-1079. [PMID: 36503397 DOI: 10.2174/1389200224666221209144420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/24/2022] [Accepted: 11/11/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Iron-chelation therapy is life-saving in patients on a chronic transfusion regimen as it reduces organ damage related to iron deposition in the tissues. Deferasirox, an iron-chelator, is characterized by pharmacokinetics variability, and some patients may discontinue the treatment due to toxicities. OBJECTIVE Understanding whether deferasirox plasma levels are related to patients' specific characteristics could help to optimize DFX dosage. METHODS We analyzed deferasirox plasma concentration in 57 transfusion-dependent anemic patients using the HPLC method in this prospective-retrospective cohort study. All outpatients (3 to 98 years) were treated with deferasirox (film-coated tablet) for at least one year (median dose, 16.5 mg/Kg once a day). Deferasirox plasma concentration was normalized for dose/Kg (C/dose) and corrected with a linear regression model that relates C/dose and the time of blood sampling (Cref/dose). RESULTS No significant differences in Cref/dose were found between males and females, either between different types of hemoglobinopathies or depending on the presence of the UGT1A1*28 polymorphism. Cref/dose has a positive and significant correlation with age, creatinine, and direct bilirubin. Cref/dose, instead, has a negative and significant correlation with Liver Iron Concentration (LIC), ferritin, and eGFR. Cref/dose was significantly different between three age categories <18yrs, 18-50yrs, and >50yrs, with Cref/dose median values of 1.0, 1.2, and 1.5, respectively. CONCLUSION The study evidenced that to ensure the efficacy of deferasirox in terms of control over LIC and, at the same time, a lesser influence on renal function, the dose of the drug to be administered to an elderly patient could be reduced.
Collapse
Affiliation(s)
- Valeria Marini
- Clinical Pharmacology Unit, EO Ospedali Galliera, Mura delle Cappuccine, n. 14. I-16128 Genoa, Italy
- Department of Internal Medicine, Clinical Pharmacology and Toxicology Unit, University of Genoa, Viale Benedetto XV, n. 2. I-16132 Genoa, Italy
| | - Valeria Maria Pinto
- Centro della Microcitemia, Anemie Congenite e Dismetabolismo del Ferro, EO Ospedali Galliera, Mura delle Cappuccine, n. 14. I-16128 Genoa, Italy
| | - Manuela Stella
- Clinical Pharmacology Unit, EO Ospedali Galliera, Mura delle Cappuccine, n. 14. I-16128 Genoa, Italy
- Department of Internal Medicine, Clinical Pharmacology and Toxicology Unit, University of Genoa, Viale Benedetto XV, n. 2. I-16132 Genoa, Italy
| | - Carmen Fucile
- Unit of Addiction and Hepatology, Alcohological Regional Center, ASL3 San Martino Hospital, Largo R. Benzi, n. 10, I-16132 Genoa, Italy
| | - Francesca Lantieri
- Health Science Department, Biostatistics Unit, University of Genoa, Via Pastore, n. 1. I-16132 Genoa, Italy
| | - Giacomo Luci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi, n.10. I-56126 Pisa, Italy
| | - Barbara Gianesin
- Centro della Microcitemia, Anemie Congenite e Dismetabolismo del Ferro, EO Ospedali Galliera, Mura delle Cappuccine, n. 14. I-16128 Genoa, Italy
- For Anemia Foundation, Via Garibaldi, n. 7. I-16124 Genoa, Italy
| | - Lorenzo Bacigalupo
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, EO Ospedali Galliera, Mura delle Cappuccine, n. 14. I-16128 Genoa, Italy
| | - Gian Luca Forni
- Centro della Microcitemia, Anemie Congenite e Dismetabolismo del Ferro, EO Ospedali Galliera, Mura delle Cappuccine, n. 14. I-16128 Genoa, Italy
| | - Francesca Mattioli
- Clinical Pharmacology Unit, EO Ospedali Galliera, Mura delle Cappuccine, n. 14. I-16128 Genoa, Italy
- Department of Internal Medicine, Clinical Pharmacology and Toxicology Unit, University of Genoa, Viale Benedetto XV, n. 2. I-16132 Genoa, Italy
| |
Collapse
|
5
|
Pharmacological and clinical evaluation of deferasirox formulations for treatment tailoring. Sci Rep 2021; 11:12581. [PMID: 34131221 PMCID: PMC8206201 DOI: 10.1038/s41598-021-91983-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/20/2021] [Indexed: 01/19/2023] Open
Abstract
Deferasirox (DFX) is the newest among three different chelators available to treat iron overload in iron-loading anaemias, firstly released as Dispersible Tablets (DT) and more recently replaced by Film-Coated Tablets (FCT). In this retrospective observational study, pharmacokinetics, pharmacodynamics, and safety features of DFX treatment were analyzed in 74 patients that took both formulations subsequently under clinical practice conditions. Bioavailability of DFX FCT compared to DT resulted higher than expected [Cmax: 99.5 (FCT) and 69.7 (DT) μMol/L; AUC: 1278 (FCT) and 846 (DT), P < 0.0001]. DFX FCT was also superior in scalability among doses. After one year of treatment for each formulation, no differences were observed between the treatments in the overall iron overload levels; however, DFX FCT but not DT showed a significant dose–response correlation [Spearman r (dose-serum ferritin variation): − 0.54, P < 0.0001]. Despite being administered at different dosages, the long-term safety profile was not different between formulations: a significant increase in renal impairment risk was observed for both treatments and it was reversible under strict monitoring (P < 0.002). Altogether, these data constitute a comprehensive comparison of DFX formulations in thalassaemia and other iron-loading anaemias, confirming the effectiveness and safety characteristics of DFX and its applicability for treatment tailoring.
Collapse
|
6
|
Liu H, Yang N, Meng S, Zhang Y, Zhang H, Zhang W. Iron chelation therapy for myelodysplastic syndrome: a systematic review and meta-analysis. Clin Exp Med 2020; 20:1-9. [PMID: 31712933 DOI: 10.1007/s10238-019-00592-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 10/30/2019] [Indexed: 01/19/2023]
Abstract
Iron overload remains a concern in myelodysplastic syndrome (MDS) patients especially those requiring recurrent blood transfusions. Whether iron chelating therapy (ICT) is beneficial to the long-term survival of myelodysplastic syndrome is still a controversial issue. Therefore, we conducted a systematic review and meta-analysis to clarify the relationship between ICT and long-term survival in patients with MDS. A total of 14 studies involving 7242 participants were identified; the outcomes revealed that for patients with MDS, ICT resulted in a lower risk of mortality compared to those with no ICT (HR 0.57; 95% CI 0.44-0.70; P < 0.001); what is more, ICT led to a lower risk of leukemia transformation (HR 0.70; 95% CI 0.52-0.93; P = 0.016). Results of subgroup analyses based on adequate ICT or any ICT, low/int-1 IPSS or unclassified IPSS and study types indicated that the ICT had a beneficial role in all these groups of patients.
Collapse
Affiliation(s)
- Hailing Liu
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Nan Yang
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Shan Meng
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Yang Zhang
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Hui Zhang
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China
| | - Wanggang Zhang
- Department of Clinical Hematology, Second Affiliated Hospital of Xi'an Jiaotong University, West Five Road, No. 157, Xi'an, 710004, Shaanxi Province, China.
| |
Collapse
|
7
|
Ho PJ, Hiwase D, Ramakrishna R, Viiala N, Solterbeck A, Traficante R, Zor E, Gervasio OL, High LM, Ross DM, Bowden DK. Cardiac and hepatic siderosis in myelodysplastic syndrome, thalassemia and diverse causes of transfusion-dependent anemia: the TIMES study. Hemasphere 2019; 3:e224. [PMID: 31723837 PMCID: PMC6746020 DOI: 10.1097/hs9.0000000000000224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/30/2019] [Accepted: 03/20/2019] [Indexed: 01/19/2023] Open
Abstract
Supplemental Digital Content is available in the text The significant morbidity and mortality associated with iron overload can be reduced by effective iron chelation. Magnetic resonance imaging (MRI) provides accurate and reproducible iron load assessment. The aim of this epidemiological study was to assess the prevalence and severity of cardiac and hepatic siderosis by MRI and to evaluate the impact of MRI on clinical management in patients with transfusion-dependent anemia and non-transfusion-dependent thalassemia (NTDT). We enrolled 243 patients with myelodysplastic syndromes (MDS), thalassemia major (TM), NTDT or other chronic anemia. Overall, 10% and 48% had cardiac and hepatic siderosis, respectively. Mean liver iron concentration (LIC) was above target range in all groups; mean myocardial T2∗ was normal. Hepatic siderosis was more prevalent than myocardial siderosis in patients with MDS, occurring in 54.4% and 4.4% of patients, respectively. As also observed in patients with NTDT or other anemia, hepatic siderosis was present in a large proportion of MDS patients who were chelation naïve (57.7%), as well as in patients receiving iron chelation therapy (ICT) (52.4%), despite a lower transfusion load compared with TM. Correlation between LIC and serum ferritin was observed across diseases; however, not all patients requiring ICT could be identified with serum ferritin alone, as serum ferritin underestimated LIC in 4.4% and overestimated LIC in 7.5% of patients. Exploratory analyses showed serum ferritin thresholds for liver siderosis detected by MRI at approximately 300 ng/mL higher in MDS than in TM. Most patients reported low–medium adherence to ICT; MRI assessment led to change in ICT in 46% of evaluable patients, including 52% of MDS patients. Accurate organ iron monitoring by MRI facilitated appropriate initiation of chelation, dose optimization and clinical decision making. Trial registration: ClinicalTrials.gov: NCT01736540.
Collapse
Affiliation(s)
- P Joy Ho
- Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | | | | | | | | | | | - Evren Zor
- Novartis Pharmaceuticals, Sydney, Australia
| | | | | | - David M Ross
- Flinders University and Medical Centre, Adelaide, Australia
| | | |
Collapse
|
8
|
Taher AT, Weber S, Han J, Bruederle A, Porter JB. Predicting serum ferritin levels in patients with iron overload treated with the film-coated tablet of deferasirox during the ECLIPSE study. Am J Hematol 2019; 94:E15-E17. [PMID: 30346059 PMCID: PMC6587503 DOI: 10.1002/ajh.25322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Ali T. Taher
- American University of Beirut Medical Center; Beirut Lebanon
| | | | - Jackie Han
- Novartis Pharmaceuticals Corporation; East Hanover New Jersey
| | | | | |
Collapse
|
9
|
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.
Collapse
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
| | | | | | | |
Collapse
|
10
|
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.
Collapse
|
11
|
Iron overload in patients with myelodysplastic syndromes: An updated overview. Cancer 2018; 124:3979-3989. [DOI: 10.1002/cncr.31550] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/07/2018] [Accepted: 03/22/2018] [Indexed: 01/19/2023]
|
12
|
De Sanctis V, Soliman AT, Yassin MA, Di Maio S, Daar S, Elsedfy H, Soliman N, Kattamis C. Hypogonadism in male thalassemia major patients: pathophysiology, diagnosis and treatment. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:6-15. [PMID: 29451224 PMCID: PMC6179033 DOI: 10.23750/abm.v89i2-s.7082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 01/19/2023]
Abstract
Failure of pubertal growth, delay or absence of sexual development, infertility and sexual dysfunction due to hypogonadism and defective spermatogenesis are frequent and well recognized disturbances among male patients with transfusion dependent (TD) thalassaemia major (β-thal). These problems are attributed mainly to the damage caused by chronic anaemia and the deposition of excess iron in the pituitary gland and testicles. This is a short review of male pubertal disorders in patients with β-thal written by pediatric endocrinologists and haematologists with an interest and active involvement, in the diagnosis and management of these complications in this group of patients. A vigilant clinical evaluation of growth and puberty, as well as an appropriate hormonal evaluation in poly-transfused (TD β-thal) patients is strongly recommended for early detection and treatment of endocrine dysfunction. Of crucial importance also, is the implementation of an efficient chelation regime from early life, to prevent severe iron load and permanent damage to the endocrine glands, particularly those responsible for gonadal function.
Collapse
Affiliation(s)
- Vincenzo De Sanctis
- Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Cerchione C, Cerciello G, Avilia S, Della Pepa R, Pugliese N, Picardi M, Catalano L, Pane F. Management of iron overload in myelodysplastic syndromes: combined deferasirox and deferoxamine in a patient with liver disease. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:32-35. [PMID: 27893351 PMCID: PMC5770312 DOI: 10.2450/2016.0137-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/19/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Claudio Cerchione
- Correspondence: Claudio Cerchione Hematology, Azienda Ospedaliera Universitaria Federico II, Via Pansini 5, 80131 Naples, Italy, e-mail:
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Du Y, Long Z, Chen M, Han B, Hou B, Feng F. Observational Monitoring of Patients with Aplastic Anemia and Low/Intermediate-1 Risk of Myelodysplastic Syndromes Complicated with Iron Overload. Acta Haematol 2017; 138:119-128. [PMID: 28866669 DOI: 10.1159/000479422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/10/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study focuses on the iron overload (IOL) of patients with transfused aplastic anemia (AA) or a low/intermediate-1 risk of myelodysplastic syndrome (MDS). METHODS Ninety-two AA or MDS patients with IOL were prospectively recruited. Clinical data were collected every 6 months, and organ magnetic resonance imaging T2* values were collected annually. Patients with IOL were chelated. RESULTS Serum ferritin was correlated with liver T2* and pancreatic T2* in the AA and MDS groups. Transfusion amounts were correlated with serum ferritin values, liver T2*, and pancreatic T2* in the AA group. At the 6-month and 1-year evaluations, patients with sufficient chelation experienced significant decreases in serum ferritin, and those with decreased serum ferritin experienced an obvious increase in hemoglobin. At their 1-year-follow-up, patients with adequate chelation showed significant increases in hepatic T2*, cardiac T2*, and left ventricular ejection fraction (LVEF). Patients with decreased serum ferritin (including those without chelation) experienced an increase in hemoglobin, hepatic T2*, cardiac T2*, and LVEF. CONCLUSION The transfusion amount was more reliable at predicting IOL in patients with AA than in those with MDS. Adequate iron chelation can decrease serum ferritin levels and may improve hepatic T2*, cardiac T2*, and LVEF levels. A decrease in serum ferritin, even in the absence of chelation, may also benefit patients.
Collapse
Affiliation(s)
- Yali Du
- Department of Hematology, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | | | | | | | | | | |
Collapse
|
15
|
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.
Collapse
|
16
|
Taher AT, Origa R, Perrotta S, Kourakli A, Ruffo GB, Kattamis A, Goh A, Cortoos A, Huang V, Weill M, Merino Herranz R, Porter JB. New film-coated tablet formulation of deferasirox is well tolerated in patients with thalassemia or lower-risk MDS: Results of the randomized, phase II ECLIPSE study. Am J Hematol 2017; 92:420-428. [PMID: 28142202 PMCID: PMC6585741 DOI: 10.1002/ajh.24668] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 01/23/2017] [Accepted: 01/26/2017] [Indexed: 01/19/2023]
Abstract
Once‐daily deferasirox dispersible tablets (DT) have a well‐defined safety and efficacy profile and, compared with parenteral deferoxamine, provide greater patient adherence, satisfaction, and quality of life. However, barriers still exist to optimal adherence, including gastrointestinal tolerability and palatability, leading to development of a new film‐coated tablet (FCT) formulation that can be swallowed with a light meal, without the need to disperse into a suspension prior to consumption. The randomized, open‐label, phase II ECLIPSE study evaluated the safety of deferasirox DT and FCT formulations over 24 weeks in chelation‐naïve or pre‐treated patients aged ≥10 years, with transfusion‐dependent thalassemia or IPSS‐R very‐low‐, low‐, or intermediate‐risk myelodysplastic syndromes. One hundred seventy‐three patients were randomized 1:1 to DT (n = 86) or FCT (n = 87). Adverse events (overall), consistent with the known deferasirox safety profile, were reported in similar proportions of patients for each formulation (DT 89.5%; FCT 89.7%), with a lower frequency of severe events observed in patients receiving FCT (19.5% vs. 25.6% DT). Laboratory parameters (serum creatinine, creatinine clearance, alanine aminotransferase, aspartate aminotransferase and urine protein/creatinine ratio) generally remained stable throughout the study. Patient‐reported outcomes showed greater adherence and satisfaction, better palatability and fewer concerns with FCT than DT. Treatment compliance by pill count was higher with FCT (92.9%) than with DT (85.3%). This analysis suggests deferasirox FCT offers an improved formulation with enhanced patient satisfaction, which may improve adherence, thereby reducing frequency and severity of iron overload‐related complications.
Collapse
Affiliation(s)
- Ali T. Taher
- American University of Beirut Medical CenterBeirut Lebanon
| | - Raffaella Origa
- Ospedale Pediatrico Microcitemico “A. Cao,”University of CagliariCagliari Italy
| | | | - Alexandra Kourakli
- Hematology Division, Department of Internal MedicineUniversity of Patras Medical SchoolPatras Greece
| | | | | | - Ai‐Sim Goh
- Department of MedicineHospital Pulau PinangGeorgetown Penang Malaysia
| | | | - Vicky Huang
- Novartis Pharmaceuticals CorporationEast Hanover New Jersey USA
| | | | | | - John B. Porter
- Department of HaematologyUniversity College LondonLondon UK
| |
Collapse
|
17
|
Iurlo A, Cattaneo D. Treatment of Myelofibrosis: Old and New Strategies. Clin Med Insights Blood Disord 2017; 10:1179545X17695233. [PMID: 28579852 PMCID: PMC5428134 DOI: 10.1177/1179545x17695233] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 01/30/2017] [Indexed: 01/19/2023]
Abstract
Myelofibrosis (MF) is a BCR-ABL1-negative myeloproliferative neoplasm that is mainly characterised by reactive bone marrow fibrosis, extramedullary haematopoiesis, anaemia, hepatosplenomegaly, constitutional symptoms, leukaemic progression, and shortened survival. As such, this malignancy is still orphan of curative treatments; indeed, the only treatment that has a clearly demonstrated impact on disease progression is allogeneic haematopoietic stem cell transplantation, but only a minority of patients are eligible for such intensive therapy. However, more recently, the discovery of JAK2 mutations has also led to the development of small-molecule JAK1/2 inhibitors, the first of which, ruxolitinib, has been approved for the treatment of MF in the United States and Europe. In this article, we report on old and new therapeutic strategies that proved effective in early preclinical and clinical trials, and subsequently in the daily clinical practice, for patients with MF, particularly concerning the topics of anaemia, splenomegaly, iron overload, and allogeneic stem cell transplantation.
Collapse
Affiliation(s)
- Alessandra Iurlo
- Oncohematology Division, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Daniele Cattaneo
- Oncohematology Division, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, Milan, Italy
| |
Collapse
|
18
|
Myelodysplastic Syndromes and Iron Chelation Therapy. Mediterr J Hematol Infect Dis 2017; 9:e2017021. [PMID: 28293409 PMCID: PMC5333736 DOI: 10.4084/mjhid.2017.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/27/2017] [Indexed: 01/19/2023] Open
Abstract
Over recent decades we have been fortunate to witness the advent of new technologies and of an expanded knowledge and application of chelation therapies to the benefit of patients with iron overload. However, extrapolation of learnings from thalassemia to the myelodysplastic syndromes (MDS) has resulted in a fragmented and uncoordinated clinical evidence base. We’re therefore forced to change our understanding of MDS, looking with other eyes to observational studies that inform us about the relationship between iron and tissue damage in these subjects. The available evidence suggests that iron accumulation is prognostically significant in MDS, but levels of accumulation historically associated with organ damage (based on data generated in the thalassemias) are infrequent. Emerging experimental data have provided some insight into this paradox, as our understanding of iron-induced tissue damage has evolved from a process of progressive bulking of organs through high-volumes iron deposition, to one of ‘toxic’ damage inflicted through multiple cellular pathways. Damage from iron may, therefore, occur prior to reaching reference thresholds, and similarly, chelation may be of benefit before overt iron overload is seen. In this review, we revisit the scientific and clinical evidence for iron overload in MDS to better characterize the iron overload phenotype in these patients, which differs from the classical transfusional and non-transfusional iron overload syndrome. We hope this will provide a conceptual framework to better understand the complex associations between anemia, iron and clinical outcomes, to accelerate progress in this area.
Collapse
|
19
|
Shah J, McKiernan P. Optimizing Communication and Adherence to Iron Chelation Therapy From Diagnosis to Treatment in Patients With Myelodysplastic Syndromes. J Adv Pract Oncol 2016; 7:707-717. [PMID: 29670807 PMCID: PMC5902151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Myelodysplastic syndromes (MDS), a heterogeneous group of blood diseases, are usually diagnosed in older individuals, with a median age at diagnosis of more than 70 years. Anemia is a common symptom in patients with MDS and may require frequent red blood cell transfusions, which can lead to iron overload. Iron chelation therapy is recommended to decrease iron concentrations in tissue and minimize organ dysfunction. However, the currently available iron chelation therapies are associated with side effects, financial constraints, and dosing issues, which may affect patient adherence. Moreover, many patients with MDS lack an understanding of the disease and their prognosis and treatments. This review can be used in the advanced practice setting to discuss the importance of communicating with patients about MDS from the time of diagnosis and will explore strategies to enhance adherence to iron chelation therapy. An individualized approach that weighs the risks and benefits of treatment for older patients with MDS will allow advanced practitioners to set expectations while developing adherence strategies to optimize outcomes. This approach provides a platform for advanced practitioners to communicate with patients to ensure they understand the natural history of MDS, their individual prognoses, and the goals of both active treatment and supportive care.
Collapse
Affiliation(s)
- Jayshree Shah
- Hackensack University Medical Center, Hackensack, New Jersey
| | | |
Collapse
|
20
|
Saeki I, Yamamoto N, Yamasaki T, Takami T, Maeda M, Fujisawa K, Iwamoto T, Matsumoto T, Hidaka I, Ishikawa T, Uchida K, Tani K, Sakaida I. Effects of an oral iron chelator, deferasirox, on advanced hepatocellular carcinoma. World J Gastroenterol 2016; 22:8967-8977. [PMID: 27833388 PMCID: PMC5083802 DOI: 10.3748/wjg.v22.i40.8967] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/06/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the inhibitory effects of deferasirox (DFX) against hepatocellular carcinoma (HCC) through basic and clinical studies.
METHODS In the basic study, the effect of DFX was investigated in three hepatoma cell lines (HepG2, Hep3B, and Huh7), as well as in an N-nitrosodiethylamine-induced murine HCC model. In the clinical study, six advanced HCC patients refractory to chemotherapy were enrolled. The initial dose of DFX was 10 mg/kg per day and was increased by 10 mg/kg per day every week, until the maximum dose of 30 mg/kg per day. The duration of a single course of DFX therapy was 28 consecutive days. In the event of dose-limiting toxicity (according to the Common Terminology Criteria for Adverse Events v.4.0), DFX dose was reduced.
RESULTS Administration of DFX inhibited the proliferation of hepatoma cell lines and induced the activation of caspase-3 in a dose-dependent manner in vitro. In the murine model, DFX treatment significantly suppressed the development of liver tumors (P < 0.01), and significantly upregulated the mRNA expression levels of hepcidin (P < 0.05), transferrin receptor 1 (P < 0.05), and hypoxia inducible factor-1α (P < 0.05) in both tumor and non-tumor tissues, compared with control mice. In the clinical study, anorexia and elevated serum creatinine were observed in four and all six patients, respectively. However, reduction in DFX dose led to decrease in serum creatinine levels in all patients. After the first course of DFX, one patient discontinued the therapy. We assessed the tumor response in the remaining five patients; one patient exhibited stable disease, while four patients exhibited progressive disease. The one-year survival rate of the six patients was 17%.
CONCLUSION We demonstrated that DFX inhibited HCC in the basic study, but not in the clinical study due to dose-limiting toxicities.
Collapse
|
21
|
Del Corso L, Biale L, Parodi EL, Russo R, Filiberti R, Arboscello E. Multidisciplinary evaluation at baseline and during treatment improves the rate of compliance and efficacy of deferasirox in elderly myelodysplastic patients. Int J Clin Oncol 2016; 22:380-386. [PMID: 27771776 DOI: 10.1007/s10147-016-1042-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/12/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Deferasirox (DFX) is used to reduce iron levels in patients with myelodysplastic syndrome (MDS) who develop iron overload after chronic red blood cell infusions. However, DFX can be associated with renal and gastrointestinal toxicities, which may cause treatment interruption or discontinuation. This study aimed to determine the effectiveness and safety of DFX in patients with MDS. METHODS This multicenter, retrospective, observational study was conducted at two hospitals in Italy. Elderly patients with transfusion-dependent MDS received DFX for up to 12 months and were divided into two groups: group A comprised patients who were not under multidisciplinary assessment; group B comprised patients under multidisciplinary control. Treatment effectiveness was estimated by monitoring the serum ferritin (SF) levels throughout the study. Any treatment-related adverse events (AEs), clinically relevant analytical alterations, and reasons for treatment discontinuation were monitored. RESULTS The study included 44 patients (13 female, 31 male; median age 77.0 years). At 3 months, SF levels decreased by ≥20 % in 29 and 31 % of patients in groups A and B, respectively, in 17 and 36 % of patients at 6 months, and in 22 and 58 % at 12 months. The most common AEs were diarrhea and increased serum creatinine, which were more frequent in group A. The discontinuation rate after renal AE was 15 and 5 % in groups A and B, respectively. CONCLUSION Multidisciplinary evaluation can be an effective strategy for monitoring renal function in patients on DFX therapy, to improve treatment adherence and overall efficacy in elderly patients with MDS.
Collapse
Affiliation(s)
- Lisette Del Corso
- Internal Medicine, Department of Hematology and Oncology, IRCCS AOU San Martino-IST, Largo R. Benzi, 10, 16132, Genoa, Italy
| | - Lucia Biale
- Blood Bank, Department of Health Management, AOU City Health Presidium Molinette, Corso Bramante 88, 10126, Turin, Italy
| | - Emanuele Luigi Parodi
- Nephrology, Department of Internal Medicine and Medical Specialties, IRCCS AOU San Martino-IST, Largo R. Benzi, 10, 16132, Genoa, Italy
| | - Rodolfo Russo
- Nephrology, Department of Internal Medicine and Medical Specialties, IRCCS AOU San Martino-IST, Largo R. Benzi, 10, 16132, Genoa, Italy
| | - Rosa Filiberti
- Clinical Epidemiology, IRCCS AOU San Martino-IST, Largo R. Benzi, 10, 16132, Genoa, Italy
| | - Eleonora Arboscello
- Internal Medicine, Department of Hematology and Oncology, IRCCS AOU San Martino-IST, Largo R. Benzi, 10, 16132, Genoa, Italy.
| |
Collapse
|
22
|
Hassan MAM, Tolba OA. Iron chelation monotherapy in transfusion-dependent beta-thalassemia major patients: a comparative study of deferasirox and deferoxamine. Electron Physician 2016; 8:2425-31. [PMID: 27382454 PMCID: PMC4930264 DOI: 10.19082/2425] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/06/2016] [Indexed: 01/19/2023] Open
Abstract
Introduction Iron overload is the primary cause of mortality and morbidity in thalassemia major (TM) despite advances in chelation therapy. The aim of this study was to compare the effectiveness and safety of deferasirox (DFX) and deferoxamine (DFO) as iron-chelating agents in patients with transfusion-dependent β-thalassemia major. Methods This prospective randomized study included 60 patients with transfusion-dependent β-TM during the period from September 2014 to September 2015. Their ages were ≥ 6 years, and they had serum ferritin above 1500 μg/L and were on irregular DFO therapy. Patients had regular packed red cell transfusion in a dose of 10 mL/kg/session. They were randomized to receive DFX (single oral daily dose of 20–40 mg/kg/day) or DFO (20–50 mg/kg/day via subcutaneous infusion over 8–10 hours, 5 days a week). Iron overload was determined by serum ferritin level. The primary endpoint was decrease of serum ferritin level below 1500 μg/L. The secondary endpoint was drug safety. Results Both drugs significantly reduced serum ferritin (p < 0.001). At the end of follow-up, there were no significant differences between the two groups in serum ferritin levels (p = 0.673) and in percent reduction of ferritin (p = 0.315). There were no significant differences between the two groups in the total amount of blood transfusion (p = 0.166) and average iron intake (p = 0.227). There were no mortalities or any serious adverse effects, neutropenia, arthropathy, or pulmonary toxicity. Gastrointestinal upset and skin rash occurred more frequently with DFX than with DFO (p = 0.254 and 0.095, respectively). Conclusion With appropriate dosing and compliance with drugs, both DFX and DFO are generally well tolerated, safe, and effective in reducing serum ferritin levels in iron-overloaded, regularly-transfused thalassemia major patients. Therefore, oral DFX is recommended for more convenience and adherence to the treatment regimen.
Collapse
Affiliation(s)
| | - Omar Atef Tolba
- Ph.D., Consultant of Pediatrics, Cairo University Children's Hospital, Department of Pediatrics, Cairo University, Egypt
| |
Collapse
|
23
|
[Advances in the treatment of severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 36:711-5. [PMID: 26462649 PMCID: PMC7348265 DOI: 10.3760/cma.j.issn.0253-2727.2015.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
24
|
Ricchi P, Marsella M. Profile of deferasirox for the treatment of patients with non-transfusion-dependent thalassemia syndromes. Drug Des Devel Ther 2016; 9:6475-82. [PMID: 26719673 PMCID: PMC4687615 DOI: 10.2147/dddt.s40694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
It has been clearly shown that iron overload adds progressively significant morbidity and mortality in patients with non-transfusion-dependent thalassemia (NTDT). The lack of physiological mechanisms to eliminate the excess of iron requires effective iron chelation therapy. The reduced compliance to deferoxamine and the risk of severe hematological adverse events during deferiprone treatment have limited the use of both these drugs to correct iron imbalance in NTDT. According to the principles of evidence-based medicine, following the demonstration of the effectiveness and the safety of deferasirox (Exjade®) in a prospective, randomized, controlled trial, deferasirox was approved by the US Food and Drug Administration in May 2013 for the treatment of iron overload associated with NTDT. This review, assessing the available scientific literature, will focus on the profile of DFX in the treatment of non-transfusional hemosiderosis in patients with NTDT.
Collapse
Affiliation(s)
- Paolo Ricchi
- UOSD Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "Antonio Cardarelli", Naples, Italy
| | - Maria Marsella
- UOSD Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "Antonio Cardarelli", Naples, Italy ; UOC Pediatria, Azienda Ospedaliera di Rilievo Nazionale G. Rummo, Benevento, Italy
| |
Collapse
|
25
|
de Swart L, Hendriks JCM, van der Vorm LN, Cabantchik ZI, Evans PJ, Hod EA, Brittenham GM, Furman Y, Wojczyk B, Janssen MCH, Porter JB, Mattijssen VEJM, Biemond BJ, MacKenzie MA, Origa R, Galanello R, Hider RC, Swinkels DW. Second international round robin for the quantification of serum non-transferrin-bound iron and labile plasma iron in patients with iron-overload disorders. Haematologica 2015; 101:38-45. [PMID: 26385212 DOI: 10.3324/haematol.2015.133983] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/18/2015] [Indexed: 01/19/2023] Open
Abstract
Non-transferrin-bound iron and its labile (redox active) plasma iron component are thought to be potentially toxic forms of iron originally identified in the serum of patients with iron overload. We compared ten worldwide leading assays (6 for non-transferrin-bound iron and 4 for labile plasma iron) as part of an international inter-laboratory study. Serum samples from 60 patients with four different iron-overload disorders in various treatment phases were coded and sent in duplicate for analysis to five different laboratories worldwide. Some laboratories provided multiple assays. Overall, highest assay levels were observed for patients with untreated hereditary hemochromatosis and β-thalassemia intermedia, patients with transfusion-dependent myelodysplastic syndromes and patients with transfusion-dependent and chelated β-thalassemia major. Absolute levels differed considerably between assays and were lower for labile plasma iron than for non-transferrin-bound iron. Four assays also reported negative values. Assays were reproducible with high between-sample and low within-sample variation. Assays correlated and correlations were highest within the group of non-transferrin-bound iron assays and within that of labile plasma iron assays. Increased transferrin saturation, but not ferritin, was a good indicator of the presence of forms of circulating non-transferrin-bound iron. The possibility of using non-transferrin-bound iron and labile plasma iron measures as clinical indicators of overt iron overload and/or of treatment efficacy would largely depend on the rigorous validation and standardization of assays.
Collapse
Affiliation(s)
- Louise de Swart
- Departments of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan C M Hendriks
- Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lisa N van der Vorm
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Z Ioav Cabantchik
- Department of Biochemical Chemistry, Hebrew University of Jerusalem, Israel
| | | | - Eldad A Hod
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Gary M Brittenham
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | | | - Boguslaw Wojczyk
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Mirian C H Janssen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - John B Porter
- Department of Haematology, University College London, UK
| | | | - Bart J Biemond
- Department of Hematology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marius A MacKenzie
- Departments of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Raffaella Origa
- Department of Biomedical Science and Biotechnology, Regional Microcythemia Hospital, University of Cagliari, Italy
| | - Renzo Galanello
- Department of Biomedical Science and Biotechnology, Regional Microcythemia Hospital, University of Cagliari, Italy
| | - Robert C Hider
- Institute of Pharmaceutical Science, King's College London, UK
| | - Dorine W Swinkels
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
26
|
Saliba AN, Harb AR, Taher AT. Iron chelation therapy in transfusion-dependent thalassemia patients: current strategies and future directions. J Blood Med 2015; 6:197-209. [PMID: 26124688 PMCID: PMC4476479 DOI: 10.2147/jbm.s72463] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Transfusional iron overload is a major target in the care of patients with transfusion-dependent thalassemia (TDT) and other refractory anemias. Iron accumulates in the liver, heart, and endocrine organs leading to a wide array of complications. In this review, we summarize the characteristics of the approved iron chelators, deferoxamine, deferiprone, and deferasirox, and the evidence behind the use of each, as monotherapy or as part of combination therapy. We also review the different guidelines on iron chelation in TDT. This review also discusses future prospects and directions in the treatment of transfusional iron overload in TDT whether through innovation in chelation or other therapies, such as novel agents that improve transfusion dependence.
Collapse
Affiliation(s)
- Antoine N Saliba
- Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut, Beirut, Lebanon
| | - Afif R Harb
- Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut, Beirut, Lebanon
| |
Collapse
|
27
|
Abstract
Iron accumulation is a consequence of regular red cell transfusions, and can occur as a result of ineffective erythropoiesis secondary to increased intestinal iron absorption, in patients with various anemias. Without appropriate treatment, iron overload can lead to increased morbidity and mortality. Deferasirox is an oral iron chelator effective for reduction of body iron in iron-overloaded patients with transfusion-dependent anemias and non-transfusion-dependent thalassemia, with a well-established safety profile. This review summarizes the clinical pharmacokinetics, pharmacodynamics, and drug-drug interaction profile of deferasirox, and the claims supporting once-daily dosing for effective chelation. Sustained labile plasma iron suppression is observed with no rebound between doses, protecting organs from potential tissue damage. Increased iron excretion positively correlates with increased deferasirox exposure; to optimize iron removal transfusional iron intake, body iron burden and safety parameters should also be considered. Deferasirox dispersible tablets should be taken ≥30 min before food due to an effect of food on bioavailability. Dosing is consistent across pediatric and adult patients and there is no ethnic sensitivity. Dose adjustment is required for patients with hepatic impairment and may be considered upon coadministration with strong uridine diphosphate glucuronosyltransferase inducers or bile acid sequestrants (coadministration should be avoided where possible), and patients should be monitored upon coadministration with cytochrome P450 (CYP) 3A4/5, CYP2C8, or CYP1A2 substrates. Coadministration with hydroxyurea, a fetal hemoglobin modulator, does not appear to impact deferasirox pharmacokinetics. In summary, a substantial body of clinical and pharmacokinetic data are available for deferasirox to guide its optimal use in multiple patient populations and clinical circumstances.
Collapse
|
28
|
Manduzio P. Deferasirox in a refractory anemia after other treatment options: case report and literature review. Clin Case Rep 2015; 3:361-7. [PMID: 26185629 PMCID: PMC4498843 DOI: 10.1002/ccr3.262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/17/2014] [Accepted: 02/20/2015] [Indexed: 01/19/2023] Open
Abstract
Deferasirox, represents an effective iron chelator drug in lower risk myelodysplastic syndromes. Reduction in oxidative stress is responsible of the hematologic improvement but further explanation may impact on its benefit. Biological and clinical studies are necessary to better define mechanisms of action, assess toxicities, and predicting factors of response.
Collapse
Affiliation(s)
- Palma Manduzio
- Department of Clinical Pathology, Riuniti University Hospital, Immunohematology and Transfusion Medicine Foggia, Italy ; Department of Oncology and Haematology, Marche Nord Hospital, Haematology and Haematopoietic Stem Cell Transplant Center Pesaro, Italy
| |
Collapse
|
29
|
Piga A, Fracchia S, Lai ME, Cappellini MD, Hirschberg R, Habr D, Wegener A, Bouillaud E, Forni GL. Deferasirox effect on renal haemodynamic parameters in patients with transfusion-dependent β thalassaemia. Br J Haematol 2014; 168:882-90. [PMID: 25402221 DOI: 10.1111/bjh.13217] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/01/2014] [Indexed: 01/19/2023]
Abstract
Some patients with β thalassaemia experience non-progressive creatinine increases with deferasirox, mostly within normal limits; the mechanisms involved are not fully elucidated. The effects of deferasirox on renal haemodynamics, including glomerular filtration rate (GFR) and renal plasma flow (RPF), were investigated in a Phase I, open-label study in β thalassaemia major patients with iron overload. Patients received deferasirox 30 mg/kg/d up to Week 8, followed by a 2-week washout period, and extended treatment up to Week 104 with a 4-week washout period. In the short-term study (n = 11), mean GFR and RPF declined from baseline to Week 8 (mean [%] change:-9·2 [-9·5%] and -105·7 ml/min [-17·8%], respectively). A similar pattern was observed during the long-term study (n = 5); mean GFR and RPF decreased up to Week 52 (-19·1 [-17·7%] and -155·6 ml/min [-26·1%]), with similar change at Week 104 (-18·4 [-17·2%] and -115·9 ml/min [-19·6%]). Measures returned to baseline values after each washout. Serum creatinine and creatinine clearance followed a similar pattern. Effects of deferasirox on renal haemodynamics were mild and reversible for up to 2 years of treatment, with no progressive worsening of renal function over time. www.clinicaltrials.gov: NCT00560820.
Collapse
|
30
|
Abstract
Recent advances in the treatment of aplastic anemia (AA) made most of patients to expect to achieve a long-term survival. Allogeneic stem cell transplantation (SCT) from HLA-matched sibling donor (MSD-SCT) is a preferred first-line treatment option for younger patients with severe or very severe AA, whereas immunosuppressive treatment (IST) is an alternative option for others. Horse anti-thymocyte globuline (ATG) with cyclosporin A (CsA) had been a standard IST regimen with acceptable response rate. Recently, horse ATG had been not available and replaced with rabbit ATG in most countries. Subsequently, recent comparative studies showed that the outcomes of patients who received rabbit ATG/CsA were similar or inferior compared to those who received horse ATG/CsA. Therefore, further studies to improve the outcomes of IST, including additional eltrombopag, are necessary. On the other hand, the upper age limit of patients who are able to receive MSD-SCT as first-line treatment is a current issue because of favorable outcomes of MSD-SCT of older patients using fludarabine-based conditioning. In addition, further studies to improve the outcomes of patients who receive allogeneic SCT from alternative donors are needed. In this review, current issues and the newly emerging trends that may improve their outcomes in near futures will be discussed focusing the management of patients with AA.
Collapse
Affiliation(s)
- Seung Hwan Shin
- Department of Hematology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Eun Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
31
|
Meerpohl JJ, Schell LK, Rücker G, Fleeman N, Motschall E, Niemeyer CM, Bassler D. Deferasirox for managing iron overload in people with myelodysplastic syndrome. Cochrane Database Syst Rev 2014; 2014:CD007461. [PMID: 25348770 PMCID: PMC7202239 DOI: 10.1002/14651858.cd007461.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The myelodysplastic syndrome (MDS) comprises a diverse group of haematopoietic stem cell disorders. Due to symptomatic anaemia, most people with MDS require supportive therapy including repeated red blood cell (RBC) transfusions. In combination with increased iron absorption, this contributes to the accumulation of iron resulting in secondary iron overload and the risk of organ dysfunction and reduced life expectancy. Since the human body has no natural means of removing excess iron, iron chelation therapy, i.e. the pharmacological treatment of iron overload, is usually recommended. However, it is unclear whether or not the newer oral chelator deferasirox leads to relevant benefit. OBJECTIVES To evaluate the effectiveness and safety of oral deferasirox for managing iron overload in people with myelodysplastic syndrome (MDS). SEARCH METHODS We searched the following databases up to 03 April 2014: MEDLINE, EMBASE, The Cochrane Library, Biosis Previews, Web of Science, Derwent Drug File and four trial registries: Current Controlled Trials (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), ICTRP (www.who.int./ictrp/en/), and German Clinical Trial Register (www.drks.de). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing deferasirox with no therapy, placebo or with another iron-chelating treatment schedule. DATA COLLECTION AND ANALYSIS We did not identify any trials eligible for inclusion in this review. MAIN RESULTS No trials met our inclusion criteria. However, we identified three ongoing and one completed trial (published as an abstract only and in insufficient detail to permit us to decide on inclusion) comparing deferasirox with deferoxamine, placebo or no treatment. AUTHORS' CONCLUSIONS We planned to report evidence from RCTs that evaluated the effectiveness of deferasirox compared to either placebo, no treatment or other chelating regimens, such as deferoxamine, in people with MDS. However, we did not identify any completed RCTs addressing this question.We found three ongoing and one completed RCT (published as an abstract only and in insufficient detail) comparing deferasirox with deferoxamine, placebo or no treatment and data will hopefully be available soon. These results will be important to inform physicians and patients on the advantages and disadvantages of this treatment option.
Collapse
Affiliation(s)
- Joerg J Meerpohl
- Medical Center ‐ University of FreiburgGerman Cochrane CentreBerliner Allee 29FreiburgGermany79110
| | - Lisa K Schell
- Medical Center ‐ University of FreiburgGerman Cochrane CentreBerliner Allee 29FreiburgGermany79110
| | - Gerta Rücker
- Medical Center ‐ University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Nigel Fleeman
- University of LiverpoolLiverpool Reviews & Implementation Group2nd Floor, Sherrington BuildingsAshton StreetLiverpoolUKL69 3GE
| | - Edith Motschall
- Medical Center ‐ University of FreiburgCenter for Medical Biometry and Medical InformaticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Charlotte M Niemeyer
- University Medical Center FreiburgPediatric Hematology & Oncology, Center for Pediatrics & Adolescent MedicineMathildenstrasse 1FreiburgGermany79106
| | - Dirk Bassler
- University Hospital ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
| | | |
Collapse
|
32
|
Díaz-García JD, Gallegos-Villalobos A, Gonzalez-Espinoza L, Sanchez-Niño MD, Villarrubia J, Ortiz A. Deferasirox nephrotoxicity-the knowns and unknowns. Nat Rev Nephrol 2014; 10:574-86. [PMID: 25048549 DOI: 10.1038/nrneph.2014.121] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In 2005, the oral iron chelator deferasirox was approved by the FDA for clinical use as a first-line therapy for blood-transfusion-related iron overload. Nephrotoxicity is the most serious and frequent adverse effect of deferasirox treatment. This nephrotoxicity can present as an acute or chronic decrease in glomerular filtration rate (GFR). Features of proximal tubular dysfunction might also be present. In clinical trials and observational studies, GFR is decreased in 30-100% of patients treated with deferasirox, depending on dose, method of assessment and population studied. Nephrotoxicity is usually nonprogressive and/or reversible and rapid iron depletion is one of several risk factors. Scarce data are available on the molecular mechanisms of nephrotoxicity and the reasons for the specific proximal tubular sensitivity to the drug. Although deferasirox promotes apoptosis of cultured proximal tubular cells, the trigger has not been well characterized. Observational studies are required to track current trends in deferasirox prescription, assess the epidemiology of deferasirox nephrotoxicity in routine clinical practice, explore the effect on outcomes of various monitoring and dose-adjustment protocols and elucidate the long-term consequences of the different features of nephrotoxicity. Deferasirox nephrotoxicity can be more common in the elderly; thus, specific efforts should be dedicated to investigate the effect of deferasirox use in this group of patients.
Collapse
Affiliation(s)
- Juan Daniel Díaz-García
- Escuela Superior de Medicina del Instituto Politécnico Nacional, Avenida Salvador Díaz Mirón s/n, 11340 Ciudad de México, México
| | | | | | | | - Jesus Villarrubia
- Hospital Ramon y Cajal, Carretera de Colmenar Viejo km. 9,100, 28034 Madrid, Spain
| | - Alberto Ortiz
- Unidad de Diálisis, Fundación Jiménez Díaz-IRSIN, Avenida Reyes Católicos 2, 28040 Madrid, Spain
| |
Collapse
|
33
|
Watanabe J, Sato K, Horiuchi T, Kato S, Hikota R, Maekawa T, Yamamura T, Kobayashi A, Osawa Y, Kobayashi S, Kimura F. Elevated total iron-binding capacity as a predictor of response to deferasirox therapy in the setting of chronic iron overload. Int J Hematol 2014; 100:254-9. [PMID: 24986748 DOI: 10.1007/s12185-014-1624-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 06/16/2014] [Accepted: 06/16/2014] [Indexed: 01/19/2023]
Abstract
It is difficult to predict the efficacy of deferasirox (DFX) as its pharmacokinetics varies among patients. The area under the curve (AUC) is reportedly useful for determining adequate DFX dosage; however, serum concentration measurements are often challenging. Effective DFX dosage is thus defined by assessing the efficacy of this agent in clinical practice. To analyze a predictive response marker to DFX therapy for use in adjusting the effective dosage during the early treatment phase, we retrospectively evaluated 39 DFX-treated patients. We defined response as a >40 % decrease in serum ferritin concentration from the pretreatment level. A maximum elevation of the total iron-binding capacity (TIBC) correlated with response in a multivariate analysis of iron metabolic markers (R (2) = 0.37, p < 0.001). A receiver operating characteristic curve analysis revealed that TIBC elevation had an AUC of 0.85 (p < 0.001) and the optimal cut-off value of TIBC elevation was 150 µg/dl. TIBC elevation of >150 µg/dl is a favorable predictor of effective ferritin reduction in DFX therapy (hazard ratio 29.6, 95 % confidence interval 4.8-183.6; p < 0.001). DFX therapy with TIBC monitoring may enable the determination of the minimum effective DFX dosage.
Collapse
Affiliation(s)
- Junichi Watanabe
- Division of Hematology, Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Coates TD. Physiology and pathophysiology of iron in hemoglobin-associated diseases. Free Radic Biol Med 2014; 72:23-40. [PMID: 24726864 PMCID: PMC4940047 DOI: 10.1016/j.freeradbiomed.2014.03.039] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 01/19/2023]
Abstract
Iron overload and iron toxicity, whether because of increased absorption or iron loading from repeated transfusions, can be major causes of morbidity and mortality in a number of chronic anemias. Significant advances have been made in our understanding of iron homeostasis over the past decade. At the same time, advances in magnetic resonance imaging have allowed clinicians to monitor and quantify iron concentrations noninvasively in specific organs. Furthermore, effective iron chelators are now available, including preparations that can be taken orally. This has resulted in substantial improvement in mortality and morbidity for patients with severe chronic iron overload. This paper reviews the key points of iron homeostasis and attempts to place clinical observations in patients with transfusional iron overload in context with the current understanding of iron homeostasis in humans.
Collapse
Affiliation(s)
- Thomas D Coates
- Children׳s Center for Cancer and Blood Diseases, Children׳s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA.
| |
Collapse
|
35
|
Impact of iron overload and potential benefit from iron chelation in low-risk myelodysplastic syndrome. Blood 2014; 124:873-81. [PMID: 24923296 DOI: 10.1182/blood-2014-03-563221] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Myelodysplastic syndromes (MDSs) are a group of heterogeneous clonal bone marrow disorders characterized by ineffective hematopoiesis, peripheral blood cytopenias, and potential for malignant transformation. Lower/intermediate-risk MDSs are associated with longer survival and high red blood cell (RBC) transfusion requirements resulting in secondary iron overload. Recent data suggest that markers of iron overload portend a relatively poor prognosis, and retrospective analysis demonstrates that iron chelation therapy is associated with prolonged survival in transfusion-dependent MDS patients. New data provide concrete evidence of iron's adverse effects on erythroid precursors in vitro and in vivo. Renewed interest in the iron field was heralded by the discovery of hepcidin, the main serum peptide hormone negative regulator of body iron. Evidence from β-thalassemia suggests that regulation of hepcidin by erythropoiesis dominates regulation by iron. Because iron overload develops in some MDS patients who do not require RBC transfusions, the suppressive effect of ineffective erythropoiesis on hepcidin may also play a role in iron overload. We anticipate that additional novel tools for measuring iron overload and a molecular-mechanism-driven description of MDS subtypes will provide a deeper understanding of how iron metabolism and erythropoiesis intersect in MDSs and improve clinical management of this patient population.
Collapse
|
36
|
Garbowski MW, Carpenter JP, Smith G, Roughton M, Alam MH, He T, Pennell DJ, Porter JB. Biopsy-based calibration of T2* magnetic resonance for estimation of liver iron concentration and comparison with R2 Ferriscan. J Cardiovasc Magn Reson 2014; 16:40. [PMID: 24915987 PMCID: PMC4064805 DOI: 10.1186/1532-429x-16-40] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 05/22/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND There is a need to standardise non-invasive measurements of liver iron concentrations (LIC) so clear inferences can be drawn about body iron levels that are associated with hepatic and extra-hepatic complications of iron overload. Since the first demonstration of an inverse relationship between biopsy LIC and liver magnetic resonance (MR) using a proof-of-concept T2* sequence, MR technology has advanced dramatically with a shorter minimum echo-time, closer inter-echo spacing and constant repetition time. These important advances allow more accurate calculation of liver T2* especially in patients with high LIC. METHODS Here, we used an optimised liver T2* sequence calibrated against 50 liver biopsy samples on 25 patients with transfusional haemosiderosis using ordinary least squares linear regression, and assessed the method reproducibility in 96 scans over an LIC range up to 42 mg/g dry weight (dw) using Bland-Altman plots. Using mixed model linear regression we compared the new T2*-LIC with R2-LIC (Ferriscan) on 92 scans in 54 patients with transfusional haemosiderosis and examined method agreement using Bland-Altman approach. RESULTS Strong linear correlation between ln(T2*) and ln(LIC) led to the calibration equation LIC = 31.94(T2*)-1.014. This yielded LIC values approximately 2.2 times higher than the proof-of-concept T2* method. Comparing this new T2*-LIC with the R2-LIC (Ferriscan) technique in 92 scans, we observed a close relationship between the two methods for values up to 10 mg/g dw, however the method agreement was poor. CONCLUSIONS New calibration of T2* against liver biopsy estimates LIC in a reproducible way, correcting the proof-of-concept calibration by 2.2 times. Due to poor agreement, both methods should be used separately to diagnose or rule out liver iron overload in patients with increased ferritin.
Collapse
Affiliation(s)
- Maciej W Garbowski
- Haematology Department, University College London Hospitals, London, UK
- University College London, London, UK
| | - John-Paul Carpenter
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK
- Imperial College London, London, UK
| | - Gillian Smith
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK
- Imperial College London, London, UK
| | | | - Mohammed H Alam
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK
- Imperial College London, London, UK
| | - Taigang He
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK
- Cardiovascular Sciences Research Centre, St George’s University of London, London, UK
| | - Dudley J Pennell
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK
- Imperial College London, London, UK
| | - John B Porter
- Haematology Department, University College London Hospitals, London, UK
- University College London, London, UK
| |
Collapse
|
37
|
Abstract
The myelodysplastic syndromes (MDS) are a group of clonal hematopoietic disorders characterized by bone marrow failure and a risk of progression to acute myelogenous leukemia (AML). A precise diagnosis is critical, because there is overlap between the clinical and laboratory findings of MDS and other malignant and nonmalignant hematologic disorders. Several prognostic scoring systems (IPSS, WPSS, LR-PSS, and IPSS-R) assess a patient's risk of progression to AML and overall survival. Many patients are elderly, so age and comorbidities are an important consideration. Patients with lower-risk disease are treated with growth factors (erythropoietin stimulating agents and/or G-CSF) and immunomodulatory agents (antithymocyte globulin and/or lenalidomide). Patients with higher-risk disease have a higher risk of progression to AML and are treated with hypomethylating agents (azacitidine or decitabine) and allogeneic stem cell transplantation if appropriate. Recent laboratory studies have increased our understanding of the pathophysiology of this disease. Mutations in genes effecting ribosomes, splicing of RNA and epigenetics have been discovered. It is likely that these breakthroughs will lead to newer classes of targeted therapies against this disease.
Collapse
Affiliation(s)
- Karen Seiter
- New York Medical College, Room 250 Munger Pavilion, Valhalla, NY 10595, USA.
| |
Collapse
|
38
|
Jang JH, Lee JH, Yoon SS, Jo DY, Kim HJ, Chung J, Lee JW. Korean guideline for iron chelation therapy in transfusion-induced iron overload. J Korean Med Sci 2013; 28:1563-72. [PMID: 24265517 PMCID: PMC3835496 DOI: 10.3346/jkms.2013.28.11.1563] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 08/20/2013] [Indexed: 01/19/2023] Open
Abstract
Many Korean patients with transfusion-induced iron overload experience serious clinical sequelae, including organ damage, and require lifelong chelation therapy. However, due to a lack of compliance and/or unavailability of an appropriate chelator, most patients have not been treated effectively. Deferasirox (DFX), a once-daily oral iron chelator for both adult and pediatric patients with transfusion-induced iron overload, is now available in Korea. The effectiveness of deferasirox in reducing or maintaining body iron has been demonstrated in many studies of patients with a variety of transfusion-induced anemias such as myelodysplastic syndromes, aplastic anemia, and other chronic anemias. The recommended initial daily dose of DFX is 20 mg/kg body weight, taken on an empty stomach at least 30 min before food and serum ferritin levels should be maintained below 1000 ng/mL. To optimize the management of transfusion-induced iron overload, the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) reviewed the general consensus on iron overload and the Korean data on the clinical benefits of iron chelation therapy, and developed a Korean guideline for the treatment of iron overload.
Collapse
Affiliation(s)
- Jun Ho Jang
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Soo Yoon
- Division of Hematology-Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Deog-Yeon Jo
- Division of Hematology-Oncology, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyeoung-Joon Kim
- Division of Hematology-Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Jooseop Chung
- Division of Hematology-Oncology, Pusan National University Hospital, Busan, Korea
| | - Jong Wook Lee
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
39
|
Diagnosis and treatment of primary myelodysplastic syndromes in adults: recommendations from the European LeukemiaNet. Blood 2013; 122:2943-64. [PMID: 23980065 DOI: 10.1182/blood-2013-03-492884] [Citation(s) in RCA: 478] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Within the myelodysplastic syndrome (MDS) work package of the European LeukemiaNet, an Expert Panel was selected according to the framework elements of the National Institutes of Health Consensus Development Program. A systematic review of the literature was performed that included indexed original papers, indexed reviews and educational papers, and abstracts of conference proceedings. Guidelines were developed on the basis of a list of patient- and therapy-oriented questions, and recommendations were formulated and ranked according to the supporting level of evidence. MDSs should be classified according to the 2008 World Health Organization criteria. An accurate risk assessment requires the evaluation of not only disease-related factors but also of those related to extrahematologic comorbidity. The assessment of individual risk enables the identification of fit patients with a poor prognosis who are candidates for up-front intensive treatments, primarily allogeneic stem cell transplantation. A high proportion of MDS patients are not eligible for potentially curative treatment because of advanced age and/or clinically relevant comorbidities and poor performance status. In these patients, the therapeutic intervention is aimed at preventing cytopenia-related morbidity and preserving quality of life. A number of new agents are being developed for which the available evidence is not sufficient to recommend routine use. The inclusion of patients into prospective clinical trials is strongly recommended.
Collapse
|
40
|
Abstract
Deferasirox is a once-daily, oral iron chelator that is widely used in the management of patients with transfusional hemosiderosis. Several Phase II trials along with their respective extension studies as well as a Phase III trial have established the efficacy and safety of this novel agent in transfusion-dependent patients with β-thalassemia, sickle-cell disease and bone marrow-failure syndromes, including myelodysplastic syndrome and aplastic anemia. Data from various clinical trials show that a deferasirox dose of 20 mg/kg/day stabilizes serum ferritin levels and liver iron concentration, while a dose of 30-40 mg/kg/day reduces these parameters and achieves negative iron balance in red cell transfusion-dependent patients with iron overload. Across various pivotal clinical trials, deferasirox was well tolerated, with the most common adverse events being gastrointestinal disturbances, skin rash, nonprogressive increases in serum creatinine, and elevations in liver enzyme levels. Longer-term extension studies have also confirmed the efficacy and safety of deferasirox. However, it is essential that patients on deferasirox therapy are monitored regularly to ensure timely management for any adverse events that may occur with long-term therapy.
Collapse
Affiliation(s)
- Preeti Chaudhary
- Jane Ann Nohl Division of Hematology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Vinod Pullarkat
- Jane Ann Nohl Division of Hematology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
41
|
Abstract
During the last 30 years, in addition to the considerable progress made in control and prevention of thalassemias(3), there have also been major advances in their symptomatic management, at least in wealthier countries where appropriate facilities are available. Remarkable improvements in survival in the severe forms of thalassemia have followed the more judicious use of blood transfusion and, in particular, the ability to manage the iron accumulation resulting from transfusion with its severe and ultimately lethal effects on endocrine and cardiac function.
Collapse
Affiliation(s)
- Nancy F Olivieri
- Hemoglobinopathy Research University Health Network, Toronto, Ontario M5G 2C4, Canada
| | | |
Collapse
|
42
|
Taher AT, Viprakasit V, Musallam KM, Cappellini MD. Treating iron overload in patients with non-transfusion-dependent thalassemia. Am J Hematol 2013; 88:409-15. [PMID: 23475638 PMCID: PMC3652024 DOI: 10.1002/ajh.23405] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 01/21/2013] [Accepted: 01/23/2013] [Indexed: 01/19/2023]
Abstract
Despite receiving no or only occasional blood transfusions, patients with non-transfusion-dependent thalassemia (NTDT) have increased intestinal iron absorption and can accumulate iron to levels comparable with transfusion-dependent patients. This iron accumulation occurs more slowly in NTDT patients compared to transfusion-dependent thalassemia patients, and complications do not arise until later in life. It remains crucial for these patients' health to monitor and appropriately treat their iron burden. Based on recent data, including a randomized clinical trial on iron chelation in NTDT, a simple iron chelation treatment algorithm is presented to assist physicians with monitoring iron burden and initiating chelation therapy in this group of patients. Am. J. Hematol. 88:409–415, 2013. © 2013 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Ali T. Taher
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirut Lebanon
| | - Vip Viprakasit
- Department of Pediatrics and Siriraj‐Thalassemia CenterFaculty of MedicineSiriraj HospitalMahidol UniversityBangkok Thailand
| | - Khaled M. Musallam
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirut Lebanon
- Department of Medicine and Medical SpecialitiesUniversitá di MilanoCa' Granda Foundation IRCCSMilan Italy
| | - M. Domenica Cappellini
- Department of Medicine and Medical SpecialitiesUniversitá di MilanoCa' Granda Foundation IRCCSMilan Italy
| |
Collapse
|
43
|
Adams RLC, Bird RJ. Safety and efficacy of deferasirox in the management of transfusion-dependent patients with myelodysplastic syndrome and aplastic anaemia: a perspective review. Ther Adv Hematol 2013; 4:93-102. [PMID: 23610617 DOI: 10.1177/2040620712472355] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Deferasirox is an orally administered, once-daily iron chelator with a generally good safety and efficacy profile. Reported adverse events in the older myelodysplastic population are somewhat different to the more intensively investigated and younger thalassaemic population. Renal impairment is the most concerning adverse event, but this is reversible if identified and the drug is withdrawn early. Gastrointestinal effects, particularly diarrhoea, can be troublesome for older patients, but can be minimized with tailored therapy. Negative iron balance can be achieved in most patients with a median dose of 20 mg/kg/day, and doses up to 40 mg/kg are possible in patients with severe iron overload, who are at risk of cardiac decompensation.
Collapse
|
44
|
Lee JW, Yoon SS, Shen ZX, Ganser A, Hsu HC, El-Ali A, Habr D, Martin N, Porter JB. Hematologic responses in patients with aplastic anemia treated with deferasirox: a post hoc analysis from the EPIC study. Haematologica 2013; 98:1045-8. [PMID: 23585526 DOI: 10.3324/haematol.2012.077669] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Reports are emerging of hematologic responses associated with iron chelation therapy; however, studies are limited in aplastic anemia patients. Deferasirox reduced iron overload in aplastic anemia patients enrolled in the EPIC (Evaluation of Patients' Iron Chelation with Exjade(®)) study (n=116). A post hoc analysis of hematologic responses was conducted on 72 patients with evaluable hematologic parameters (according to UK guideline criteria), 24 of whom received deferasirox without concomitant immunosuppressive treatment. Partial hematologic responses were observed in 11 of 24 (45.8%) patients; all became transfusion-independent. One patient had an additional platelet response and one patient had an additional platelet and hemoglobin response. Mean serum ferritin levels at end of study were significantly reduced in partial hematologic responders (n=11; -3948 ± 4998 ng/mL; baseline 6693 ± 7014 ng/mL; percentage change from baseline -45.7%; P=0.0029). In non-responders, the reduction in serum ferritin was less pronounced (n=13; -2021 ± 3242 ng/mL; baseline 4365 ± 3063 ng/mL; % change from baseline -27.6%; P=0.0171). Alongside reduction in iron overload, deferasirox may, therefore, improve hematologic parameters in a subset of aplastic anemia patients. Further investigation is required to elucidate the mechanisms involved.
Collapse
Affiliation(s)
- Jong Wook Lee
- The Catholic University of Korea, Seoul, South Korea.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Porter JB, Elalfy MS, Taher AT, Aydinok Y, Chan LL, Lee SH, Sutcharitchan P, Habr D, Martin N, El-Beshlawy A. Efficacy and safety of deferasirox at low and high iron burdens: results from the EPIC magnetic resonance imaging substudy. Ann Hematol 2012; 92:211-9. [PMID: 23086508 PMCID: PMC3542426 DOI: 10.1007/s00277-012-1588-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 09/23/2012] [Indexed: 01/19/2023]
Abstract
The effect of deferasirox dosing tailored for iron burden and iron loading based on liver iron concentration (LIC) was assessed over 1 year in less versus more heavily iron-overloaded patients in a substudy of the Evaluation of Patients' Iron Chelation with Exjade®. Deferasirox starting dose was 10-30 mg/kg/day, depending on blood transfusion frequency, with recommended dose adjustments every 3 months. Therapeutic goals were LIC maintenance or reduction in patients with baseline LIC <7 or ≥7 mg Fe/g dry weight (dw), respectively. Changes in LIC (R2-magnetic resonance imaging) and serum ferritin after 1 year were assessed. Adverse events (AEs) and laboratory parameters were monitored throughout. Of 374 patients, 71 and 303 had baseline LIC <7 and ≥7 mg Fe/g dw, respectively; mean deferasirox doses were 20.7 and 27.1 mg/kg/day (overall average time to dose increase, 24 weeks). At 1 year, mean LIC and median serum ferritin levels were maintained in the low-iron cohort (-0.02 ± 2.4 mg Fe/g dw, -57 ng/mL; P = not significant) and significantly decreased in the high-iron cohort (-6.1 ± 9.1 mg Fe/g dw, -830 ng/mL; P < 0.0001). Drug-related gastrointestinal AEs, mostly mild to moderate, were more frequently reported in the <7 versus ≥7 mg Fe/g dw cohort (39.4 versus 20.8 %; P = 0.001) and were not confounded by diagnosis, dosing, ethnicity, or hepatitis B and/or C history. Reported serum creatinine increases did not increase in low- versus high-iron cohort patients. Deferasirox doses of 20 mg/kg/day maintained LIC <7 mg Fe/g dw and doses of 30 mg/kg/day were required for net iron reduction in the high-iron cohort, with clinically manageable safety profiles. The higher incidence of gastrointestinal AEs at lower iron burdens requires further investigation.
Collapse
Affiliation(s)
- J B Porter
- UCL Cancer Institute, Department of Haematology, University College London, 72 Huntley Street, London, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
Elucidating the molecular basis for the regulation of iron uptake, storage, and distribution is necessary to understand iron homeostasis. Pharmacological tools are emerging to identify and distinguish among different iron transport pathways. Stimulatory or inhibitory small molecules with effects on iron uptake can help characterize the mechanistic elements of iron transport and the roles of the transporters involved in these processes. In particular, iron chelators can serve as potential pharmacological tools to alleviate diseases of iron overload. This review focuses on the pharmacology of iron transport, introducing iron transport membrane proteins and known inhibitors.
Collapse
Affiliation(s)
- Shaina L Byrne
- Department of Genetics and Complex Diseases, Harvard School of Public Health, Boston, Massachusetts 02115, USA
| | | | | |
Collapse
|
47
|
Guidelines on haemovigilance of post-transfusional iron overload. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 11:128-39. [PMID: 22790272 DOI: 10.2450/2012.0114-11] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 12/19/2011] [Indexed: 01/19/2023]
|
48
|
An update on iron chelation therapy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 10:411-22. [PMID: 22790257 DOI: 10.2450/2012.0008-12] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 02/21/2012] [Indexed: 02/07/2023]
|
49
|
Shah J, Kurtin SE, Arnold L, Lindroos-Kolqvist P, Tinsley S. Management of Transfusion-Related Iron Overload in Patients With Myelodysplastic Syndromes. Clin J Oncol Nurs 2012; 16 Suppl:37-46. [DOI: 10.1188/12.cjon.s1.37-46] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
50
|
Gattermann N, Jarisch A, Schlag R, Blumenstengel K, Goebeler M, Groschek M, Losem C, Procaccianti M, Junkes A, Leismann O, Germing U. Deferasirox treatment of iron-overloaded chelation-naïve and prechelated patients with myelodysplastic syndromes in medical practice: results from the observational studies eXtend and eXjange. Eur J Haematol 2012; 88:260-8. [PMID: 22023452 PMCID: PMC3505370 DOI: 10.1111/j.1600-0609.2011.01726.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2011] [Indexed: 01/19/2023]
Abstract
EXtend and eXjange were prospective, 1-yr, non-interventional, observational, multicentre studies that investigated deferasirox, a once-daily oral iron chelator, in iron-overloaded chelation-naïve and prechelated patients with myelodysplastic syndromes (MDS), respectively, treated in the daily-routine setting of office-based physicians. No inclusion or exclusion criteria or additional monitoring procedures were applied. Deferasirox was administered as recommended in the European Summary of Product Characteristics. Haematological parameters and adverse events (AEs) were collected at two-monthly intervals. Data from 123 chelation-naïve patients with MDS (mean age 70.4 yrs) with median baseline serum ferritin level of 2679 (range 184-16,500) ng/mL, and 44 prechelated patients with MDS (mean age 69.6 yrs) with median baseline serum ferritin level of 2442 (range 521-8565) ng/mL, were assessed. The mean prescribed daily dose of deferasirox at the first visit was 15.7 and 18.7 mg/kg/d, respectively. Treatment with deferasirox produced a significant reduction in median serum ferritin levels in chelation-naïve patients with MDS from 2679 to 2000 ng/mL (P = 0.0002) and a pronounced decrease in prechelated patients with MDS from 2442 to 2077 ng/mL (P = 0.06). The most common drug-related AEs were gastrointestinal, increased serum creatinine levels and rash. These studies demonstrate that deferasirox used in physicians' medical practices is effective in managing iron burden in transfusion-dependent patients with MDS.
Collapse
Affiliation(s)
- Norbert Gattermann
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Düsseldorf, Germany.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|