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Musallam KM, Sheth S, Cappellini MD, Forni GL, Maggio A, Taher AT. Anemia and iron overload as prognostic markers of outcomes in β-thalassemia. Expert Rev Hematol 2024; 17:631-642. [PMID: 39037857 DOI: 10.1080/17474086.2024.2383420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 07/18/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION Ineffective erythropoiesis and subsequent anemia as well as primary and secondary (transfusional) iron overload are key drivers for morbidity and mortality outcomes in patients with β-thalassemia. AREAS COVERED In this review, we highlight evidence from observational studies evaluating the association between measures of anemia and iron overload versus outcomes in both non-transfusion-dependent and transfusion-dependent forms of β-thalassemia. EXPERT OPINION Several prognostic thresholds have been identified with implications for patient management. These have also formed the basis for the design of novel therapy clinical trials by informing eligibility and target endpoints. Still, several data gaps persist in view of the challenge of assessing prospective long-term outcomes in a chronic disease. Pooling insights on the prognostic value of different measures of disease mechanism will be key to design future scoring systems that can help optimize patient management.
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Affiliation(s)
- Khaled M Musallam
- Center for Research on Rare Blood Disorders (CR-RBD), Burjeel Medical City, Abu Dhabi, United Arab Emirates
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Sujit Sheth
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca' Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
| | | | - Aurelio Maggio
- Campus of Haematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo, Italy
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Han X, He W, Liang D, Liu X, Zhou J, de Thé H, Zhu J, Yuan H. Creg1 Regulates Erythroid Development via TGF-β/Smad2-Klf1 Axis in Zebrafish. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024:e2402804. [PMID: 38953462 DOI: 10.1002/advs.202402804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/04/2024] [Indexed: 07/04/2024]
Abstract
Understanding the regulation of normal erythroid development will help to develop new potential therapeutic strategies for disorders of the erythroid lineage. Cellular repressor of E1A-stimulated genes 1 (CREG1) is a glycoprotein that has been implicated in the regulation of tissue homeostasis. However, its role in erythropoiesis remains largely undefined. In this study, it is found that CREG1 expression increases progressively during erythroid differentiation. In zebrafish, creg1 mRNA is preferentially expressed within the intermediate cell mass (ICM)/peripheral blood island (PBI) region where primitive erythropoiesis occurs. Loss of creg1 leads to anemia caused by defective erythroid differentiation and excessive apoptosis of erythroid progenitors. Mechanistically, creg1 deficiency results in reduced activation of TGF-β/Smad2 signaling pathway. Treatment with an agonist of the Smad2 pathway (IDE2) could significantly restore the defective erythroid development in creg1-/- mutants. Further, Klf1, identified as a key target gene downstream of the TGF-β/Smad2 signaling pathway, is involved in creg1 deficiency-induced aberrant erythropoiesis. Thus, this study reveals a previously unrecognized role for Creg1 as a critical regulator of erythropoiesis, mediated at least in part by the TGF-β/Smad2-Klf1 axis. This finding may contribute to the understanding of normal erythropoiesis and the pathogenesis of erythroid disorders.
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Affiliation(s)
- Xiao Han
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- CNRS-LIA Hematology and Cancer, Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Wenxin He
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- CNRS-LIA Hematology and Cancer, Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Dongguo Liang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Xiaohui Liu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- CNRS-LIA Hematology and Cancer, Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jun Zhou
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- CNRS-LIA Hematology and Cancer, Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Hugues de Thé
- CNRS-LIA Hematology and Cancer, Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Université de Paris 7/INSERM/CNRS UMR 944/7212, Equipe Labellisée Ligue Nationale Contre le Cancer, Hôpital St. Louis, Paris, 75010, France
| | - Jun Zhu
- CNRS-LIA Hematology and Cancer, Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Université de Paris 7/INSERM/CNRS UMR 944/7212, Equipe Labellisée Ligue Nationale Contre le Cancer, Hôpital St. Louis, Paris, 75010, France
| | - Hao Yuan
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- CNRS-LIA Hematology and Cancer, Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
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Xu J, Yan Y, Zong S, Ye W, Zheng J, Min C, Wang Q, Li Z. Rapid and sustained response to luspatercept and eltrombopag combined treatment in one case of clonal cytopenias of undetermined significance with prior failure to cyclosporin and androgen therapy: a case report. Ther Adv Hematol 2024; 15:20406207241260353. [PMID: 38911444 PMCID: PMC11191611 DOI: 10.1177/20406207241260353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/22/2024] [Indexed: 06/25/2024] Open
Abstract
Clonal cytopenia of undetermined significance (CCUS) has the characteristics of high-risk transformation into myelodysplastic syndromes. At present, there are few effective treatments for CCUS, and there is no consensus or evidence-based recommendation. We present a case demonstrating a rapid, significant and sustained response to combined treatment with luspatercept and eltrombopag, following the failure of cyclosporin and androgen therapy. Even after discontinuing luspatercept for 10 months, trilineage haematopoiesis remained normal with the use of cyclosporin and other haematopoietic stimulants. This case suggests that the inhibition of transforming growth factor-β could potentially have an immunomodulatory effect, thereby promoting the recovery of haematopoietic function. Luspatercept, along with Acalabrutinib or Cyclosporine, may synergistically stimulate haematopoiesis.
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Affiliation(s)
- Jing Xu
- Department of Hematology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yixin Yan
- Department of Hematology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Siwen Zong
- The Second Clinical Medical College, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Wencan Ye
- Department of Hematology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jifu Zheng
- Department of Hematology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Chao Min
- Department of Hematology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Qingming Wang
- Department of Hematology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Zhenjiang Li
- Department of Hematology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No. 1 Minde Road, Donghu District, Nanchang, Jiangxi 330006, China
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Wake M, Palin A, Belot A, Berger M, Lorgouilloux M, Bichon M, Papworth J, Bayliss L, Grimshaw B, Rynkiewicz N, Paterson J, Poindron A, Spearing E, Carter E, Hudson R, Campbell M, Petzer V, Besson-Fournier C, Latour C, Largounez A, Gourbeyre O, Fay A, Coppin H, Roth MP, Theurl I, Germaschewski V, Meynard D. A human anti-matriptase-2 antibody limits iron overload, α-globin aggregates, and splenomegaly in β-thalassemic mice. Blood Adv 2024; 8:1898-1907. [PMID: 38241484 PMCID: PMC11021894 DOI: 10.1182/bloodadvances.2023012010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/21/2024] Open
Abstract
ABSTRACT Iron plays a major role in the deterioration of β-thalassemia. Indeed, the high levels of transferrin saturation and iron delivered to erythroid progenitors are associated with production of α-globin precipitates that negatively affect erythropoiesis. Matriptase-2/TMPRSS6, a membrane-bound serine protease expressed in hepatocytes, negatively modulates hepcidin production and thus is a key target to prevent iron overload in β-thalassemia. To address safety concerns raised by the suppression of Tmprss6 by antisense oligonucleotides or small interfering RNA, we tested a fully human anti-matriptase-2 antibody, RLYB331, which blocks the protease activity of matriptase-2. When administered weekly to Hbbth3/+ mice, RLYB331 induced hepcidin expression, reduced iron loading, prevented the formation of toxic α-chain/heme aggregates, reduced ros oxygen species formation, and improved reticulocytosis and splenomegaly. To increase the effectiveness of RLYB331 in β-thalassemia treatment even further, we administered RLYB331 in combination with RAP-536L, a ligand-trapping protein that contains the extracellular domain of activin receptor type IIB and alleviates anemia by promoting differentiation of late-stage erythroid precursors. RAP-536L alone did not prevent iron overload but significantly reduced apoptosis in the erythroid populations of the bone marrow, normalized red blood cell counts, and improved hemoglobin and hematocrit levels. Interestingly, the association of RLYB331 with RAP-536L entirely reversed the β-thalassemia phenotype in Hbbth3/+ mice and simultaneously corrected iron overload, ineffective erythropoiesis, splenomegaly, and hematological parameters, suggesting that a multifunctional molecule consisting of the fusion of RLYB331 with luspatercept (human version of RAP-536L) would allow administration of a single medication addressing simultaneously the different pathophysiological aspects of β-thalassemia.
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Affiliation(s)
- Matthew Wake
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | - Anaïs Palin
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Audrey Belot
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Mathieu Berger
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Megane Lorgouilloux
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Margot Bichon
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | | | - Luke Bayliss
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | | | | | - Jemima Paterson
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | - Alicia Poindron
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | - Erin Spearing
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | - Emily Carter
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | - Robyne Hudson
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | - Millie Campbell
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
| | - Verena Petzer
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Céline Besson-Fournier
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Chloé Latour
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Amélie Largounez
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Ophélie Gourbeyre
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Alexis Fay
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Hélène Coppin
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Marie-Paule Roth
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Igor Theurl
- Kymab Ltd, Babraham Research Campus, Cambridge, United Kingdom
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Delphine Meynard
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, Institut National de Recherche pour l'Agriculture, l'alimentation et l'Environnement, École Nationale Vétérinaire de Toulouse, Université Paul Sabatier, Toulouse, France
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Bozzini C, Busti F, Marchi G, Vianello A, Cerchione C, Martinelli G, Girelli D. Anemia in patients receiving anticancer treatments: focus on novel therapeutic approaches. Front Oncol 2024; 14:1380358. [PMID: 38628673 PMCID: PMC11018927 DOI: 10.3389/fonc.2024.1380358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
Anemia is common in cancer patients and impacts on quality of life and prognosis. It is typically multifactorial, often involving different pathophysiological mechanisms, making treatment a difficult task. In patients undergoing active anticancer treatments like chemotherapy, decreased red blood cell (RBC) production due to myelosuppression generally predominates, but absolute or functional iron deficiency frequently coexists. Current treatments for chemotherapy-related anemia include blood transfusions, erythropoiesis-stimulating agents, and iron supplementation. Each option has limitations, and there is an urgent need for novel approaches. After decades of relative immobilism, several promising anti-anemic drugs are now entering the clinical scenario. Emerging novel classes of anti-anemic drugs recently introduced or in development for other types of anemia include activin receptor ligand traps, hypoxia-inducible factor-prolyl hydroxylase inhibitors, and hepcidin antagonists. Here, we discuss their possible role in the treatment of anemia observed in patients receiving anticancer therapies.
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Affiliation(s)
- Claudia Bozzini
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Fabiana Busti
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giacomo Marchi
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Alice Vianello
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Claudio Cerchione
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Giovanni Martinelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy
- EuroBloodNet Referral Center, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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Aslan NA, Avcı E, Şenol H, Güler N. GDF11 level and its effect on prognosis in patients with acute myeloid leukemia. J Investig Med 2024; 72:341-348. [PMID: 38415361 DOI: 10.1177/10815589241238218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Acute myeloid leukemia (AML) is a hematologic malignancy characterized by the proliferation of CD34 positive self-renewing malignant hematopoietic stem cells. Previous studies have shown that the transforming growth factor beta (TGFβ) pathway plays a role in AML pathogenesis, especially by affecting the microenvironment. Growth differentiation factor 11 (GDF11) is a member of the TGFβ superfamily, involved in embryological development and known as rejuvenating factor. In this study, our aim was to determine the serum GDF11 level in patients with AML, to compare it with the control group, to determine its relationship with follistatin, vimentin, and E-cadherin levels, and to determine whether GDF11 influences AML prognosis. Serum GDF11, vimentin, follistatin, and E-cadherin levels of newly diagnosed or relapsed/refractory AML patients and age- and gender-matched control group were measured by enzyme-linked immunosorbent assay. Serum GDF11 level was higher in the patient group (263.87 ± 126.54 ng/L) compared to the control group (211.54 ± 61.47 ng/L; p = 0.035). GDF11 level did not change according to age, gender, hemoglobin level, and bone marrow blast rate. No correlation was found between GDF11 level, response rates, and survival status of the patients. A positive correlation was detected between GDF11, E-cadherin, and vimentin levels. As a conclusion, increased serum GDF11 levels in AML patients may be linked to the regeneration ability of leukemic stem cells. There is a need for studies investigating GDF11 expression in myeloblasts.
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Affiliation(s)
| | - Esin Avcı
- Pamukkale University School of Medicine, Denizli, Turkey
| | - Hande Şenol
- Pamukkale University School of Medicine, Denizli, Turkey
| | - Nil Güler
- Pamukkale University School of Medicine, Denizli, Turkey
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7
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Lin S, Zheng Y, Chen M, Xu L, Huang H. The interactions between ineffective erythropoiesis and ferroptosis in β-thalassemia. Front Physiol 2024; 15:1346173. [PMID: 38468700 PMCID: PMC10925657 DOI: 10.3389/fphys.2024.1346173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/09/2024] [Indexed: 03/13/2024] Open
Abstract
In Guangxi, Hainan, and Fujian Province in southern China, β-thalassemia is a frequent monogenic hereditary disorder that is primarily defined by hemolytic anemia brought on by inefficient erythropoiesis. It has been found that ineffective erythropoiesis in β-thalassemia is closely associated with a high accumulation of Reactive oxygen species, a product of oxidative stress, in erythroid cells. During recent years, ferroptosis is an iron-dependent lipid peroxidation that involves abnormalities in lipid and iron metabolism as well as reactive oxygen species homeostasis. It is a recently identified kind of programmed cell death. β-thalassemia patients experience increased iron release from reticuloendothelial cells and intestinal absorption of iron, ultimately resulting in iron overload. Additionally, the secretion of Hepcidin is inhibited in these patients. What counts is both ineffective erythropoiesis and ferroptosis in β-thalassemia are intricately linked to the iron metabolism and Reactive oxygen species homeostasis. Consequently, to shed further light on the pathophysiology of β-thalassemia and propose fresh ideas for its therapy, this paper reviews ferroptosis, ineffective erythropoiesis, and the way they interact.
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Affiliation(s)
- Siyang Lin
- Fujian Provincial Key Laboratory of Prenatal Diagnosis and Birth Defect, Medical Genetic Diagnosis and Therapy Center of Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- The School of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China
| | - Yanping Zheng
- Fujian Provincial Key Laboratory of Prenatal Diagnosis and Birth Defect, Medical Genetic Diagnosis and Therapy Center of Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Meihuan Chen
- Fujian Provincial Key Laboratory of Prenatal Diagnosis and Birth Defect, Medical Genetic Diagnosis and Therapy Center of Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Fujian Clinical Research Center for Maternal-Fetal Medicine, Fuzhou, China
- National Key Obstetric Clinical Specialty Construction Institution of China, Fuzhou, China
| | - Liangpu Xu
- Fujian Provincial Key Laboratory of Prenatal Diagnosis and Birth Defect, Medical Genetic Diagnosis and Therapy Center of Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Fujian Clinical Research Center for Maternal-Fetal Medicine, Fuzhou, China
- National Key Obstetric Clinical Specialty Construction Institution of China, Fuzhou, China
| | - Hailong Huang
- Fujian Provincial Key Laboratory of Prenatal Diagnosis and Birth Defect, Medical Genetic Diagnosis and Therapy Center of Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- The School of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China
- Fujian Clinical Research Center for Maternal-Fetal Medicine, Fuzhou, China
- National Key Obstetric Clinical Specialty Construction Institution of China, Fuzhou, China
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8
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Garbowski MW, Ugidos M, Risueño A, Shetty JK, Schwickart M, Hermine O, Porter JB, Thakurta A, Vodala S. Luspatercept stimulates erythropoiesis, increases iron utilization, and redistributes body iron in transfusion-dependent thalassemia. Am J Hematol 2024; 99:182-192. [PMID: 37782758 DOI: 10.1002/ajh.27102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 09/06/2023] [Accepted: 09/09/2023] [Indexed: 10/04/2023]
Abstract
Luspatercept, a ligand-trapping fusion protein, binds select TGF-β superfamily ligands implicated in thalassemic erythropoiesis, promoting late-stage erythroid maturation. Luspatercept reduced transfusion burden in the BELIEVE trial (NCT02604433) of 336 adults with transfusion-dependent thalassemia (TDT). Analysis of biomarkers in BELIEVE offers novel physiological and clinical insights into benefits offered by luspatercept. Transfusion iron loading rates decreased 20% by 1.4 g (~7 blood units; median iron loading rate difference: -0.05 ± 0.07 mg Fe/kg/day, p< .0001) and serum ferritin (s-ferritin) decreased 19.2% by 269.3 ± 963.7 μg/L (p < .0001), indicating reduced macrophage iron. However, liver iron content (LIC) did not decrease but showed statistically nonsignificant increases from 5.3 to 6.7 mg/g dw. Erythropoietin, growth differentiation factor 15, soluble transferrin receptor 1 (sTfR1), and reticulocytes rose by 93%, 59%, 66%, and 112%, respectively; accordingly, erythroferrone increased by 51% and hepcidin decreased by 53% (all p < .0001). Decreased transfusion with luspatercept in patients with TDT was associated with increased erythropoietic markers and decreasing hepcidin. Furthermore, s-ferritin reduction associated with increased erythroid iron incorporation (marked by sTfR1) allowed increased erythrocyte marrow output, consequently reducing transfusion needs and enhancing rerouting of hemolysis (heme) iron and non-transferrin-bound iron to the liver. LIC increased in patients with intact spleens, consistent with iron redistribution given the hepcidin reduction. Thus, erythropoietic and hepcidin changes with luspatercept in TDT lower transfusion dependency and may redistribute iron from macrophages to hepatocytes, necessitating the use of concomitant chelator cover for effective iron management.
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Affiliation(s)
- Maciej W Garbowski
- UCL Cancer Institute Hematology Department, University College London, University College London Hospitals, London, UK
| | - Manuel Ugidos
- BMS Center for Innovation and Translational Research Europe (CITRE), Bristol Myers Squibb, Seville, Spain
| | - Alberto Risueño
- BMS Center for Innovation and Translational Research Europe (CITRE), Bristol Myers Squibb, Seville, Spain
| | - Jeevan K Shetty
- Celgene International Sàrl a Bristol-Myers Squibb Company, Boudry, Switzerland
| | | | - Olivier Hermine
- Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Imagine Institute, INSERM Unité 1163, University of Paris, Paris, France
| | - John B Porter
- UCL Cancer Institute Hematology Department, University College London, University College London Hospitals, London, UK
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9
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El-Beshlawy A, Dewedar H, Hindawi S, Alkindi S, Tantawy AA, Yassin MA, Taher AT. Management of transfusion-dependent β-thalassemia (TDT): Expert insights and practical overview from the Middle East. Blood Rev 2024; 63:101138. [PMID: 37867006 DOI: 10.1016/j.blre.2023.101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023]
Abstract
β-Thalassemia is one of the most common monogenetic diseases worldwide, with a particularly high prevalence in the Middle East region. As such, we have developed long-standing experience with disease management and devising solutions to address challenges attributed to resource limitations. The region has also participated in the majority of clinical trials and development programs of iron chelators and more novel ineffective erythropoiesis-targeted therapy. In this review, we provide a practical overview of management for patients with transfusion-dependent β-thalassemia, primarily driven by such experiences, with the aim of transferring knowledge to colleagues in other regions facing similar challenges.
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Affiliation(s)
- Amal El-Beshlawy
- Department of Pediatric Hematology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hany Dewedar
- Thalassemia Center, Latifa Hospital, Dubai, United Arab Emirates
| | - Salwa Hindawi
- Department of Hematology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Salam Alkindi
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Azza A Tantawy
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed A Yassin
- Department of Hematology and Oncology, National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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10
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Duarte TL, Lopes M, Oliveira M, Santos AG, Vasco C, Reis JP, Antunes AR, Gonçalves A, Chacim S, Oliveira C, Porto B, Teles MJ, Moreira AC, Silva AMN, Schwessinger R, Drakesmith H, Henrique R, Porto G, Duarte D. Iron overload induces dysplastic erythropoiesis and features of myelodysplasia in Nrf2-deficient mice. Leukemia 2024; 38:96-108. [PMID: 37857886 DOI: 10.1038/s41375-023-02067-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023]
Abstract
Iron overload (IOL) is hypothesized to contribute to dysplastic erythropoiesis. Several conditions, including myelodysplastic syndrome, thalassemia and sickle cell anemia, are characterized by ineffective erythropoiesis and IOL. Iron is pro-oxidant and may participate in the pathophysiology of these conditions by increasing genomic instability and altering the microenvironment. There is, however, lack of in vivo evidence demonstrating a role of IOL and oxidative damage in dysplastic erythropoiesis. NRF2 transcription factor is the master regulator of antioxidant defenses, playing a crucial role in the cellular response to IOL in the liver. Here, we crossed Nrf2-/- with hemochromatosis (Hfe-/-) or hepcidin-null (Hamp1-/-) mice. Double-knockout mice developed features of ineffective erythropoiesis and myelodysplasia including macrocytic anemia, splenomegaly, and accumulation of immature dysplastic bone marrow (BM) cells. BM cells from Nrf2/Hamp1-/- mice showed increased in vitro clonogenic potential and, upon serial transplantation, recipients disclosed cytopenias, despite normal engraftment, suggesting defective differentiation. Unstimulated karyotype analysis showed increased chromosome instability and aneuploidy in Nrf2/Hamp1-/- BM cells. In HFE-related hemochromatosis patients, NRF2 promoter SNP rs35652124 genotype TT (predicted to decrease NRF2 expression) associated with increased MCV, consistent with erythroid dysplasia. Our results suggest that IOL induces ineffective erythropoiesis and dysplastic hematologic features through oxidative damage in Nrf2-deficient cells.
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Affiliation(s)
- Tiago L Duarte
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal.
| | - Marta Lopes
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Mónica Oliveira
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Ana G Santos
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Catarina Vasco
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Joana P Reis
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Ana Rita Antunes
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Andreia Gonçalves
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Sérgio Chacim
- Serviço de Hematologia e Transplantação de Medula Óssea, Instituto Português de Oncologia do Porto Francisco Gentil, E.P.E. (IPO Porto), Porto, Portugal
| | - Cláudia Oliveira
- Laboratório de Citogenética, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Beatriz Porto
- Laboratório de Citogenética, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Maria José Teles
- Departmento de Patologia Clínica, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Ana C Moreira
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - André M N Silva
- LAQV-REQUIMTE, Departamento de Química e Bioquímica, Faculdade de Ciências, Universidade do Porto, Porto, Portugal
- LAQV-REQUIMTE, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Ron Schwessinger
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- MRC WIMM Centre for Computational Biology, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Hal Drakesmith
- MRC Translational Immune Discovery Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Rui Henrique
- Serviço de Anatomia Patológica, IPO Porto, Porto, Portugal
- Departamento de Patologia e Imunologia Molecular, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Graça Porto
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Departamento de Patologia e Imunologia Molecular, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
- Serviço de Imuno-hemoterapia, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
| | - Delfim Duarte
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.
- Serviço de Hematologia e Transplantação de Medula Óssea, Instituto Português de Oncologia do Porto Francisco Gentil, E.P.E. (IPO Porto), Porto, Portugal.
- Departmento de Biomedicina, Faculdade de Medicina da Universidade do Porto (FMUP), Porto, Portugal.
- P.CCC - Porto Comprehensive Cancer Center Raquel Seruca, Porto, Portugal.
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11
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Nai A, Cordero-Sanchez C, Tanzi E, Pagani A, Silvestri L, Di Modica SM. Cellular and animal models for the investigation of β-thalassemia. Blood Cells Mol Dis 2024; 104:102761. [PMID: 37271682 DOI: 10.1016/j.bcmd.2023.102761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/06/2023]
Abstract
β-Thalassemia is a genetic form of anemia due to mutations in the β-globin gene, that leads to ineffective and extramedullary erythropoiesis, abnormal red blood cells and secondary iron-overload. The severity of the disease ranges from mild to lethal anemia based on the residual levels of globins production. Despite being a monogenic disorder, the pathophysiology of β-thalassemia is multifactorial, with different players contributing to the severity of anemia and secondary complications. As a result, the identification of effective therapeutic strategies is complex, and the treatment of patients is still suboptimal. For these reasons, several models have been developed in the last decades to provide experimental tools for the study of the disease, including erythroid cell lines, cultures of primary erythroid cells and transgenic animals. Years of research enabled the optimization of these models and led to decipher the mechanisms responsible for globins deregulation and ineffective erythropoiesis in thalassemia, to unravel the role of iron homeostasis in the disease and to identify and validate novel therapeutic targets and agents. Examples of successful outcomes of these analyses include iron restricting agents, currently tested in the clinics, several gene therapy vectors, one of which was recently approved for the treatment of most severe patients, and a promising gene editing strategy, that has been shown to be effective in a clinical trial. This review provides an overview of the available models, discusses pros and cons, and the key findings obtained from their study.
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Affiliation(s)
- Antonella Nai
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, IRCCS Ospedale San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, via Olgettina 58, Milan, Italy.
| | - Celia Cordero-Sanchez
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, IRCCS Ospedale San Raffaele, via Olgettina 60, Milan, Italy
| | - Emanuele Tanzi
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, IRCCS Ospedale San Raffaele, via Olgettina 60, Milan, Italy
| | - Alessia Pagani
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, IRCCS Ospedale San Raffaele, via Olgettina 60, Milan, Italy
| | - Laura Silvestri
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, IRCCS Ospedale San Raffaele, via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University, via Olgettina 58, Milan, Italy
| | - Simona Maria Di Modica
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, IRCCS Ospedale San Raffaele, via Olgettina 60, Milan, Italy
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12
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Girelli D, Marchi G. Deironing the spleen with luspatercept. Blood 2023; 142:1856-1858. [PMID: 38032674 DOI: 10.1182/blood.2023022548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Affiliation(s)
- Domenico Girelli
- University of Verona
- Azienda Ospedaliera Universitaria Integrata Verona
| | - Giacomo Marchi
- University of Verona
- Azienda Ospedaliera Universitaria Integrata Verona
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13
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Kalleda N, Flace A, Altermatt P, Ingoglia G, Doucerain C, Nyffenegger N, Dürrenberger F, Manolova V. Ferroportin inhibitor vamifeport ameliorates ineffective erythropoiesis in a mouse model of β-thalassemia with blood transfusions. Haematologica 2023; 108:2703-2714. [PMID: 37165842 PMCID: PMC10543196 DOI: 10.3324/haematol.2022.282328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/04/2023] [Indexed: 05/12/2023] Open
Abstract
β-thalassemia is an inherited anemia characterized by ineffective erythropoiesis. Blood transfusions are required for survival in transfusion-dependent β-thalassemia and are also occasionally needed in patients with non-transfusion-dependent β-thalassemia. Patients with transfusion-dependent b-thalassemia often have elevated transferrin saturation (TSAT) and non-transferrin-bound iron (NTBI) levels, which can lead to organ iron overload, oxidative stress, and vascular damage. Vamifeport is an oral ferroportin inhibitor that was previously shown to ameliorate anemia, ineffective erythropoiesis, and dysregulated iron homeostasis in the Hbbth3/+ mouse model of β-thalassemia, under non-transfused conditions. Our study aimed to assess the effects of oral vamifeport on iron-related parameters (including plasma NTBI levels) and ineffective erythropoiesis following blood transfusions in Hbbth3/+ mice. A single dose of vamifeport prevented the transient transfusion-mediated NTBI increase in Hbbth3/+ mice. Compared with vehicle treatment, vamifeport significantly increased hemoglobin levels and red blood cell counts in transfused mice. Vamifeport treatment also significantly improved ineffective erythropoiesis in the spleens of Hbbth3/+ mice, with additive effects observed when treatment was combined with repeated transfusions. Vamifeport corrected leukocyte counts and significantly improved iron-related parameters (serum transferrin, TSAT and erythropoietin levels) versus vehicle treatment in Hbbth3/+ mice, irrespective of transfusion status. In summary, vamifeport prevented transfusion-mediated NTBI formation in Hbbth3/+ mice. When given alone or combined with blood transfusions, vamifeport also ameliorated anemia, ineffective erythropoiesis, and dysregulated iron homeostasis. Administering vamifeport together with repeated blood transfusions additively ameliorated anemia and ineffective erythropoiesis in this mouse model, providing preclinical proof-of-concept for the efficacy of combining vamifeport with blood transfusions in β-thalassemia.
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Affiliation(s)
| | - Anna Flace
- Research and Non-clinical Development, CSL Vifor, St. Gallen
| | | | - Giada Ingoglia
- Research and Non-clinical Development, CSL Vifor, St. Gallen
| | | | | | | | - Vania Manolova
- Research and Non-clinical Development, CSL Vifor, St. Gallen
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14
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Saliba AN, Musallam KM, Taher AT. How I treat non-transfusion-dependent β-thalassemia. Blood 2023; 142:949-960. [PMID: 37478396 PMCID: PMC10644094 DOI: 10.1182/blood.2023020683] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/23/2023] Open
Abstract
The intricate interplay of anemia and iron overload under the pathophysiological umbrella of ineffective erythropoiesis in non-transfusion-dependent β-thalassemia (NTDT) results in a complex variety of clinical phenotypes that are challenging to diagnose and manage. In this article, we use a clinical framework rooted in pathophysiology to present 4 common scenarios of patients with NTDT. Starting from practical considerations in the diagnosis of NTDT, we delineate our strategy for the longitudinal care of patients who exhibit different constellations of symptoms and complications. We highlight the use of transfusion therapy and novel agents, such as luspatercept, in the patient with anemia-related complications. We also describe our approach to chelation therapy in the patient with iron overload. Although tackling every specific complication of NTDT is beyond the scope of this article, we touch on the management of the various morbidities and multisystem manifestations of the disease.
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Affiliation(s)
| | - Khaled M. Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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15
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Lan Z, Lv Z, Zuo W, Xiao Y. From bench to bedside: The promise of sotatercept in hematologic disorders. Biomed Pharmacother 2023; 165:115239. [PMID: 37516019 DOI: 10.1016/j.biopha.2023.115239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 07/31/2023] Open
Abstract
Sotatercept (ACE-011) is an activin receptor IIA-Fc (ActRIIA-Fc) fusion protein currently under investigation for its potential in the treatment of hematologic diseases. By impeding the activities of the overexpressed growth and differentiation factor 11 (GDF11), activin A, and other members of the transforming growth factor-β (TGF-β) superfamily, commonly found in hematologic disorders, sotatercept aims to restore the normal functioning of red blood cell maturation and osteoblast differentiation. This action is anticipated to enhance anemia management and hinder the progression of myeloma. Simultaneously, comprehensive research is ongoing to investigate sotatercept's pharmacokinetics and potential adverse reactions, thus laying a robust foundation for its prospective clinical use. In this review, we provide a detailed overview of TGF-β pathways in physiological and hematologic disorder contexts, outline the potential mechanism of sotatercept, and delve into its pharmacokinetics and clinical research advancements in various hematologic diseases. A particular emphasis is given to the relationship between sotatercept dosage and its efficacy or associated adverse reactions.
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Affiliation(s)
- Zehao Lan
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha 410011, China; Xiangya School of Medicine, Central South University, Changsha 410013, China
| | - Zhaohua Lv
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha 410011, China; Xiangya School of Medicine, Central South University, Changsha 410013, China
| | - Wanyun Zuo
- Department of Hematology, Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha 410011, China.
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16
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Musallam KM, Sheth S, Cappellini MD, Kattamis A, Kuo KHM, Taher AT. Luspatercept for transfusion-dependent β-thalassemia: time to get real. Ther Adv Hematol 2023; 14:20406207231195594. [PMID: 37645382 PMCID: PMC10460678 DOI: 10.1177/20406207231195594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- Khaled M. Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Sujit Sheth
- Division of Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca’ Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Kevin H. M. Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, 11072020 – Lebanon
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17
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Sheth S, Taher AT, Coates TD, Kattamis A, Cappellini MD. Management of luspatercept therapy in patients with transfusion-dependent β-thalassaemia. Br J Haematol 2023; 201:824-831. [PMID: 37037668 DOI: 10.1111/bjh.18801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/12/2023]
Abstract
Patients with transfusion-dependent β-thalassaemia require lifelong, regular red blood cell transfusions for survival; however, frequent blood transfusions are associated with an increased risk of iron overload, transfusion-transmitted disease and alloimmunization, as well as reduced quality of life. Luspatercept, an erythroid maturation agent that promotes late-stage erythroid maturation independently of erythropoietin, has demonstrated efficacy in reducing transfusion burden in patients with transfusion-dependent β-thalassaemia. In this review, we discuss treatment initiation, ongoing evaluation, dose adjustment and management of adverse events in transfusion-dependent patients with β-thalassaemia receiving luspatercept, and we provide guidance on how to determine whether patients are deriving clinical benefit.
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Affiliation(s)
- Sujit Sheth
- Division of Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Thomas D Coates
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles and USC Keck School of Medicine, Los Angeles, California, USA
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
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18
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Musallam KM, Taher AT, Kattamis A, Kuo KHM, Sheth S, Cappellini MD. Profile of Luspatercept in the Treatment of Anemia in Adults with Non-Transfusion-Dependent β-Thalassemia (NTDT): Design, Development and Potential Place in Therapy. Drug Des Devel Ther 2023; 17:1583-1591. [PMID: 37255740 PMCID: PMC10226484 DOI: 10.2147/dddt.s368584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/20/2023] [Indexed: 06/01/2023] Open
Abstract
Over the past decade, evidence has been mounting on the detrimental clinical sequelae of untreated anemia in patients with non-transfusion-dependent β-thalassemia (NTDT). There are no pharmacologic agents that are specifically approved for the management of anemia in NTDT, and available options such as splenectomy, transfusion therapy, and hydroxyurea each come with their own shortcomings, especially for long-term use. Luspatercept is an erythroid maturation agent that has been evaluated in a Phase 2, randomized trial and showed a significant benefit in raising hemoglobin level by at least 1 g/dL in adults with NTDT and a baseline hemoglobin level ≤10 g/dL. These data led to luspatercept's approval by the European Commission for the treatment of anemia in adults with NTDT and presents the first evidence-based approach for a novel agent that is able to ameliorate anemia in this patient population.
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Affiliation(s)
- Khaled M Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Sujit Sheth
- Division of Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca’ Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
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19
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Abstract
Advances in understanding the underlying pathophysiology of β-thalassemia have enabled efforts toward the development of novel therapeutic modalities. These can be classified into three major categories based on their ability to target different features of the underlying disease pathophysiology: correction of the α/β globin chain imbalance, targeting ineffective erythropoiesis, and targeting iron dysregulation. This article provides an overview of these different emerging therapies that are currently in development for β-thalassemia.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Ali T Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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20
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Ferraresi M, Panzieri DL, Leoni S, Cappellini MD, Kattamis A, Motta I. Therapeutic perspective for children and young adults living with thalassemia and sickle cell disease. Eur J Pediatr 2023:10.1007/s00431-023-04900-w. [PMID: 36997768 PMCID: PMC10257623 DOI: 10.1007/s00431-023-04900-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
Hemoglobinopathies, including thalassemias and sickle cell disease, are the most common monogenic diseases worldwide, with estimated annual births of more than 330,000 affected infants. Hemoglobin disorders account for about 3.4% of deaths in children under 5 years of age. The distribution of these diseases is historically linked to current or previously malaria-endemic regions; however, immigration has led to a worldwide distribution of these diseases, making them a global health problem. During the last decade, new treatment approaches and novel therapies have been proposed, some of which have the potential to change the natural history of these disorders. Indeed, the first erythroid maturation agent, luspatercept, and gene therapy have been approved for beta-thalassemia adult patients. For sickle cell disease, molecules targeting vaso-occlusion and hemoglobin S polymerization include crizanlizumab, which has been approved for patients ≥ 16 years, voxelotor approved for patients ≥ 12 years, and L-glutamine for patients older than 5 years. Conclusion: We herein present the most recent advances and future perspectives in thalassemia and sickle cell disease treatment, including new drugs, gene therapy, and gene editing, and the current clinical trial status in the pediatric populations. What is Known: • Red blood cell transfusions, iron chelation therapy and hematopoietic stem cell transplantation have been the mainstay of treatment of thalassemia patients for decades. • For sickle cell disease, until 2005, treatment strategies were mostly the same as those for thalassemia, with the option of simple transfusion or exchange transfusion. In 2007, hydroxyurea was approved for patients ≥ 2 years old. What is New: • In 2019, gene therapy with betibeglogene autotemcel (LentiGlobin BB305) was approved for TDT patients ≥ 12 years old non β0/β0 without matched sibling donor. • Starting from 2017 several new drugs, such as L-glutamine (approved only by FDA), crizanlizumab (approved by FDA and EMA for patients ≥ 16 years), and lastly voxelotor (approved by FDA and EMA for patients ≥ 12 years old).
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Affiliation(s)
- Marta Ferraresi
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy
- Università Degli Studi Di Milano, Milan, Italy
| | - Daniele Lello Panzieri
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy
- Università Degli Studi Di Milano, Milan, Italy
| | - Simona Leoni
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy
- Università Degli Studi Di Milano, Milan, Italy
| | - Maria Domenica Cappellini
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Antonis Kattamis
- Division of Pediatric Hematology-Oncology, First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Irene Motta
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza, 35, 20122, Milan, Italy.
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.
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21
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Tinsley-Vance SM, Davis M, Ajayi O. Role of Luspatercept in the Management of Lower-Risk Myelodysplastic Syndromes. J Adv Pract Oncol 2023; 14:82-87. [PMID: 36741213 PMCID: PMC9894202 DOI: 10.6004/jadpro.2023.14.1.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Treatment options are limited for patients with anemia associated with lower-risk myelodysplastic syndromes (LR-MDS). The recent approval of luspatercept for the treatment of anemia associated with very low-to intermediate-risk MDS with ring sideroblasts (RS) or with myelodysplastic/myeloproliferative neoplasm with RS and thrombocytosis has provided adult patients and practitioners with a much-needed new therapeutic option. Luspatercept is a first-in-class erythroid maturation agent that exerts its effects on later stages of erythropoiesis. In the phase III MEDALIST trial of patients with LR-MDS with RS, luspatercept (starting dose 1 mg/kg) demonstrated substantial clinical benefit (38% of patients treated with luspatercept vs. 13% of those treated with placebo [p < .001] achieved transfusion independence for ≥ 8 weeks during the first 24 weeks of treatment) and a favorable safety profile. The most common adverse events (AEs), including fatigue, asthenia, dizziness, and diarrhea, were more frequent during the first 4 treatment cycles and subsequently declined. This review provides a comprehensive overview of luspatercept treatment administration, including the mechanism of action, efficacy and safety data, management of dosing, and AEs associated with luspatercept treatment of patients with LR-MDS.
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Affiliation(s)
| | - Mark Davis
- Texas Oncology-Southwest Fort Worth, Fort Worth, Texas
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22
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Gerardo-Ramírez M, German-Ramirez N, Escobedo-Calvario A, Chávez-Rodríguez L, Bucio-Ortiz L, Souza-Arroyo V, Miranda-Labra RU, Gutiérrez-Ruiz MC, Gomez-Quiroz LE. The hepatic effects of GDF11 on health and disease. Biochimie 2022; 208:129-140. [PMID: 36584866 DOI: 10.1016/j.biochi.2022.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/14/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022]
Abstract
The growth differentiation factor 11 (GDF11), a member of the superfamily of the transforming growth factor β, has gained relevance in the last few years due to its remarkable effects in cellular biology, particularly in the nervous system, skeletal muscle, the heart, and many epithelial tissues. Some controversies have been raised about this growth factor. Many of them have been related to technical factors but also the nature of the cellular target. In liver biology and pathobiology, the GDF11 has shown to be related in many molecular aspects, with a significant impact on the physiology and the initiation and progression of the natural history of liver diseases. GDF11 has been involved as a critical regulator in lipid homeostasis, which, as it is well known, is the first step in the progression of liver disease. However, also it has been reported that the GDF11 is involved in fibrosis, senescence, and cancer. Although there are some controversies, much of the literature indicates that GDF11 displays effects tending to solve or mitigate pathological states of the liver, with reasonable evidence of correlation with other organs or systems. To a large extent, the controversy, as mentioned, is due to technical problems, such as the specificity of GDF11 antibodies, confusion with its closer family member, myostatin, and the state of differentiation in the tissues. In the present work, we reviewed the specific effects of GDF11 in the biology and pathobiology of the liver as a potential and promising factor for therapeutic intervention shortly.
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Affiliation(s)
- Monserrat Gerardo-Ramírez
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; First Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Natanael German-Ramirez
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; Posgrado en Biología Experimental, DCBS, Universidad Autónoma Metrolitana-Iztapalapa, Mexico City, Mexico
| | - Alejandro Escobedo-Calvario
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; Posgrado en Biología Experimental, DCBS, Universidad Autónoma Metrolitana-Iztapalapa, Mexico City, Mexico
| | - Lisette Chávez-Rodríguez
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; Posgrado en Biología Experimental, DCBS, Universidad Autónoma Metrolitana-Iztapalapa, Mexico City, Mexico
| | - Leticia Bucio-Ortiz
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; Laboratorio de Medicina Experimental, Unidad de Medicina Traslacional IIB/UNAM, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Verónica Souza-Arroyo
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; Laboratorio de Medicina Experimental, Unidad de Medicina Traslacional IIB/UNAM, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Roxana U Miranda-Labra
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; Laboratorio de Medicina Experimental, Unidad de Medicina Traslacional IIB/UNAM, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - María Concepción Gutiérrez-Ruiz
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; Laboratorio de Medicina Experimental, Unidad de Medicina Traslacional IIB/UNAM, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Luis E Gomez-Quiroz
- Laboratorio de Medicina Experimental y Carcinogénesis, Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City, Mexico; Laboratorio de Medicina Experimental, Unidad de Medicina Traslacional IIB/UNAM, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
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23
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Gonzalez-Lugo JD, Verma A. Targeting inflammation in lower-risk MDS. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:382-387. [PMID: 36485128 PMCID: PMC9821551 DOI: 10.1182/hematology.2022000350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The myelodysplastic syndromes (MDS) are a heterogeneous group of malignant hematopoietic stem cell disorders characterized by ineffective growth and differentiation of hematopoietic progenitors leading to peripheral blood cytopenias, dysplasia, and a variable risk of transformation to acute myelogenous leukemia. As most patients present with lower-risk disease, understanding the pathogenesis of ineffective hematopoiesis is important for developing therapies that will increase blood counts in patients with MDS. Various inflammatory cytokines are elevated in MDS and contribute to dysplastic differentiation. Inflammatory pathways mediated by interleukin (IL) 1b, IL-6, IL-1RAP, IL-8, and others lead to growth of aberrant MDS stem and progenitors while inhibiting healthy hematopoiesis. Spliceosome mutations can lead to missplicing of genes such as IRAK4, CASP8, and MAP3K, which lead to activation of proinflammatory nuclear factor κB-driven pathways. Therapeutically, targeting of ligands of the transforming growth factor β (TGF-β) pathway has led to approval of luspatercept in transfusion-dependent patients with MDS. Presently, various clinical trials are evaluating inhibitors of cytokines and their receptors in low-risk MDS. Taken together, an inflammatory microenvironment can support the pathogenesis of clonal hematopoiesis and low-risk MDS, and clinical trials are evaluating anti-inflammatory strategies in these diseases.
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Affiliation(s)
- Jesus D Gonzalez-Lugo
- Division of Hemato-Oncology, Department of Oncology, Montefiore-Einstein Cancer Center, Blood Cancer Institute, Bronx, NY
| | - Amit Verma
- Division of Hemato-Oncology, Department of Oncology, Montefiore-Einstein Cancer Center, Blood Cancer Institute, Bronx, NY
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24
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Piga A, Longo F, Gamberini MR, Voskaridou E, Ricchi P, Caruso V, Pietrangelo A, Zhang X, Shetty JK, Attie KM, Tartaglione I. Long-term safety and erythroid response with luspatercept treatment in patients with β-thalassemia. Ther Adv Hematol 2022; 13:20406207221134404. [PMID: 36505885 PMCID: PMC9726852 DOI: 10.1177/20406207221134404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 09/30/2022] [Indexed: 12/09/2022] Open
Abstract
Background β-thalassemia is a hereditary blood disorder resulting in ineffective erythropoiesis and anemia. Management of anemia with regular blood transfusions is associated with complications including iron overload. Here, we report long-term safety and efficacy results of the first clinical study of luspatercept in β-thalassemia, initiated in 2013, enrolling adults with both nontransfusion-dependent (NTD) and transfusion-dependent (TD) β-thalassemia. Objectives The objective was to report long-term safety data, for up to 5 years of treatment, for 64 patients with TD or NTD β-thalassemia, and long-term efficacy data for a subset of 63 patients with β-thalassemia who received high-dose luspatercept (0.6-1.25 mg/kg): 31 NTD and 32 TD patients. Design The study was a phase 2, noncontrolled, open-label trial comprising a dose-finding base phase and a 5-year extension phase. Methods Endpoints include safety; erythroid response over a continuous 12-week period [NTD: hemoglobin increase from baseline ⩾1.0 or ⩾1.5 g/dl; TD: red blood cell (RBC) transfusion burden reduction, ⩾20%, ⩾33%, or ⩾50%]; and changes in biomarkers of ineffective erythropoiesis, iron metabolism parameters, Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) scores, and 6-min walking distance. Results Median duration of luspatercept exposure for NTD and TD patients was 910 days (range, 40-1850) and 433 days (range, 21-1790), respectively. Seventeen of 31 (54.8%) NTD patients achieved a mean hemoglobin increase of ⩾1.5 g/dl and 19 of 32 (59.4%) TD patients achieved ⩾50% reduction in RBC transfusion burden, during any continuous 12-week period. Median cumulative duration of response was 1126 days (range, 127-1790) for NTD patients and 909 days (range, 87-1734) for TD patients. The most common treatment-related adverse events of any grade were bone pain, headache, and myalgia. Conclusion Long-term assessment of patients with β-thalassemia showed luspatercept was associated with sustained increases in hemoglobin levels in NTD patients and sustained transfusion burden reductions in TD patients. Trial registration (ClinicalTrials.gov Identifiers: NCT01749540 and NCT02268409). Plain Language Summary Long-term safety and erythroid response with luspatercept treatment in patients with β-thalassemia Background: β-thalassemia is a genetic blood disorder caused by mutations in the β-globin gene, which encodes one of the proteins that comprise hemoglobin, a key constituent of red blood cells. Patients with β-thalassemia experience anemia, the main treatment for which is blood transfusions. Long-term repeated blood transfusions lower patients' quality of life, use hospital resources, and the resulting accumulation of excess iron can cause organ failure and decrease life expectancy. The severity of the anemia experienced by patients with β-thalassemia varies; patients with transfusion-dependent β-thalassemia require regular blood transfusions, compared with those with nontransfusion-dependent β-thalassemia who require infrequent transfusions, or even none at all, to manage their symptoms. Luspatercept (Reblozyl®) is an agent that stimulates the production of red blood cells and is used to treat anemia caused by β-thalassemia. However, the long-term effects of luspatercept treatment on patients with β-thalassemia are not known.Objective: In this study, we report the long-term safety of luspatercept in 64 adult patients with either transfusion-dependent or nontransfusion-dependent β-thalassemia, and the long-term efficacy of high-dose luspatercept (0.6-1.25 mg/kg) in a subset of 63 patients.Results: The average time period that patients were treated with luspatercept was 910 days for nontransfusion-dependent β-thalassemia and 433 days for transfusion-dependent β-thalassemia. We report that in patients with nontransfusion-dependent β-thalassemia, luspatercept treatment was associated with sustained increases, just over 3 years, in hemoglobin levels. Likewise, in transfusion-dependent β-thalassemia, luspatercept treatment was associated with a sustained reduction, 2.5 years, in the amount of blood transfusion required to manage their anemia. Long-term treatment with luspatercept was not associated with any new side effects compared with previous short-term treatment studies. The most common side effects were headache (27 patients), bone pain (20 patients), and muscle pain (14 patients) with more than 90% of these patients experiencing these side effects as mild severity.Conclusion: The results of this study show that in patients with either transfusion-dependent or nontransfusion-dependent β-thalassemia, luspatercept provides lasting reduction in anemia with mostly mild and predictable side effects.
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Affiliation(s)
| | - Filomena Longo
- Department of Clinical and Biological Sciences, Turin University, Turin, Italy
| | | | - Ersi Voskaridou
- Thalassemia and Sickle Cell Center, Laiko General Hospital, Athens, Greece
| | - Paolo Ricchi
- Malattie Rare Del Globulo Rosso, AORN Cardarelli, Naples, Italy
| | | | | | | | - Jeevan K. Shetty
- Celgene International Sàrl, Bristol-Myers Squibb Company, Boudry, Switzerland
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25
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Dighriri IM, Alrabghi KK, Sulaiman DM, Alruwaili AM, Alanazi NS, Al-Sadiq AMA, Hadadi AM, Sahli BY, Qasem BA, Alotaibi MT, Asiri TT, Majrashi SM, Alotibia NT, Alhamyani AT, Alharbi AA. Efficacy and Safety of Luspatercept in the Treatment of β-Thalassemia: A Systematic Review. Cureus 2022; 14:e31570. [PMID: 36540460 PMCID: PMC9756914 DOI: 10.7759/cureus.31570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 11/17/2022] Open
Abstract
β-thalassemia is characterized by the faulty generation of hemoglobin resulting in an elevated α/β globin ratio; this led to several patients needing red blood cell (RBC) transfusions for the rest of their lives. Luspatercept is an erythroid maturation test for treating various types of anemia, including β-thalassemia. It inhibits the Smad2/3 cascade and treats β-thalassemia by downregulating the transforming growth factor-beta (TGF-β) pathway. Luspatercept was evaluated in randomized controlled trials (RCTs). However, there is still limited data. Therefore, the study aims to review the current literature to assess the efficacy of luspatercept in cure β-thalassemia and its safety. From 2015 to 2022, searches were undertaken in PubMed, Google Scholar, and Cochrane. Only RCTs published in English were eligible for inclusion. The Cochrane Collaboration tool for bias assessment was used to analyze the quality of the publications. Our search strategy revealed 94 publications, of which 12 full-text papers were read and five were chosen for this review.All five trials included 1161 participants. Of whom, 153 (13.18%) entered phase 2, and 1008 (86.82%) entered phase 3. Two articles included 153 participants, of whom 70 (45.75%) were transfusion-dependent beta-thalassemia (TD) and 83 (54.25%) were non-transfusion-dependent beta-thalassemia (NTD) of phase 2. Three articles included 1008 participants, of whom 672 (66.67%) were given luspatercept and 336 (33.33%) were given a placebo. All participants in RCTs were 18 years of age or older. In phase 2, 0.2 to 1.25 mg/kg of luspatercept was given, and in phase 3, 1.0 to 1.25 mg/kg of luspatercept was given once every three weeks. In beta-thalassemia patients, luspatercept was more effective than a placebo and well tolerated. The high dose has shown promising results in the erythroid response, measured by a drop in blood transfusions or an average rise in hemoglobin levels. Luspatercept might make patients less likely to need RBC transfusions, improve their clinical results, and improve their quality of life. Adverse events were hyperuricemia, arthralgia, dizziness, influenza hypertension, and bone pain, but they were manageable.
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Affiliation(s)
| | | | | | | | - Nader S Alanazi
- Department of Pharmacy, King Salman Specialist Hospital, Hail, SAU
| | | | - Amal M Hadadi
- Department of Pharmacy, Community Pharmacy, Jazan, SAU
| | | | | | | | - Taif T Asiri
- College of Pharmacy, King Khalid University, Abha, SAU
| | - Salman M Majrashi
- College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al Kharj, SAU
| | | | | | - Amjad A Alharbi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Ministry of Health, Hail, SAU
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26
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Shash H. Non-Transfusion-Dependent Thalassemia: A Panoramic Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101496. [PMID: 36295656 PMCID: PMC9608723 DOI: 10.3390/medicina58101496] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/08/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
Non-transfusion-dependent thalassemia (NTDT) has been considered less severe than its transfusion-dependent variants. The most common forms of NTDT include β-thalassemia intermedia, hemoglobin E/beta thalassemia, and hemoglobin H disease. Patients with NTDT develop several clinical complications, despite their regular transfusion independence. Ineffective erythropoiesis, iron overload, and hypercoagulability are pathophysiological factors that lead to morbidities in these patients. Therefore, an early and accurate diagnosis of NTDT is essential to ascertaining early interventions. Currently, several conventional management options are available, with guidelines suggested by the Thalassemia International Federation, and novel therapies are being developed in light of the advancement of the understanding of this disease. This review aimed to increase clinicians’ awareness of NTDT, from its basic medical definition and genetics to its pathophysiology. Specific complications to NTDT were reviewed, along with the risk factors for its development. The indications of different therapeutic options were outlined, and recent advancements were reviewed.
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Affiliation(s)
- Hwazen Shash
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia;
- Department of Pediatrics, King Fahad Hospital of the University, Al-Khobar 31952, Saudi Arabia
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27
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Mathieu M, Friedrich C, Ducrot N, Zannoni J, Sylvie T, Jerraya N, Rousseaux S, Chuffart F, Kosmider O, Karim Z, Park S. Luspatercept (RAP-536) modulates oxidative stress without affecting mutation burden in myelodysplastic syndromes. Ann Hematol 2022; 101:2633-2643. [PMID: 36195681 DOI: 10.1007/s00277-022-04993-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/23/2022] [Indexed: 11/27/2022]
Abstract
In low-risk myelodysplastic syndrome (LR-MDS), erythropoietin (EPO) is widely used for the treatment of chronic anemia. However, initial response to EPO has time-limited effects. Luspatercept reduces red blood cell transfusion dependence in LR-MDS patients. Here, we investigated the molecular action of luspatercept (RAP-536) in an in vitro model of erythroid differentiation of MDS, and also in a in vivo PDX murine model with primary samples of MDS patients carrying or not SF3B1 mutation. In our in vitro model, RAP-536 promotes erythroid proliferation by increasing the number of cycling cells without any impact on apoptosis rates. RAP-536 promoted late erythroid precursor maturation while decreasing intracellular reactive oxygen species level. RNA sequencing of erythroid progenitors obtained under RAP-536 treatment showed an enrichment of genes implicated in positive regulation of response to oxidative stress and erythroid differentiation. In our PDX model, RAP-536 induces a higher hemoglobin level. RAP-536 did not modify variant allele frequencies in vitro and did not have any effect against leukemic burden in our PDX model. These results suggest that RAP-536 promotes in vivo and in vitro erythroid cell differentiation by decreasing ROS level without any remarkable impact on iron homeostasis and on mutated allele burden.
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Affiliation(s)
- Meunier Mathieu
- Department of Hematology, CHU Grenoble Alpes, CS10217, 38043, Grenoble cedex 09, France.
- CNRS UMR 5309, INSERM, U1209, Université Grenoble Alpes, Institute for Advanced Bioscience, 38700, Grenoble, France.
| | - Chloé Friedrich
- Institut Cochin, Department Development, Reproduction and Cancer, 75014, Paris, France
| | - Nicolas Ducrot
- Université de Paris, INSERM, CNRS, Centre de Recherche Sur L'Inflammation (CRI), 75018, Paris, France
| | - Johanna Zannoni
- CNRS UMR 5309, INSERM, U1209, Université Grenoble Alpes, Institute for Advanced Bioscience, 38700, Grenoble, France
| | - Tondeur Sylvie
- Laboratoire de Génétique Des Hémopathies, CHU Grenoble Alpes, Grenoble, France
| | - Nelly Jerraya
- CNRS UMR 5309, INSERM, U1209, Université Grenoble Alpes, Institute for Advanced Bioscience, 38700, Grenoble, France
| | - Sophie Rousseaux
- CNRS UMR 5309, INSERM, U1209, Université Grenoble Alpes, Institute for Advanced Bioscience, 38700, Grenoble, France
| | - Florent Chuffart
- CNRS UMR 5309, INSERM, U1209, Université Grenoble Alpes, Institute for Advanced Bioscience, 38700, Grenoble, France
| | - Olivier Kosmider
- Institut Cochin, Department Development, Reproduction and Cancer, 75014, Paris, France
- Hematology Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université de Paris (APHP-CUP), 75014, Paris, France
| | - Zoubida Karim
- Université de Toulouse, INSERM, CNRS, Institut Toulousain Des Maladies Infectieuses Et Inflammatoires (Infinity), Université Paul Sabatier (UPS), Toulouse, France
| | - Sophie Park
- Department of Hematology, CHU Grenoble Alpes, CS10217, 38043, Grenoble cedex 09, France.
- CNRS UMR 5309, INSERM, U1209, Université Grenoble Alpes, Institute for Advanced Bioscience, 38700, Grenoble, France.
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28
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Abstract
Thalassaemia is a diverse group of genetic disorders with a worldwide distribution affecting globin chain synthesis. The pathogenesis of thalassaemia lies in the unbalanced globin chain production, leading to ineffective erythropoiesis, increased haemolysis, and deranged iron homoeostasis. The clinical phenotype shows heterogeneity, ranging from close to normal without complications to severe requiring lifelong transfusion support. Conservative treatment with transfusion and iron chelation has transformed the natural history of thalassaemia major into a chronic disease with a prolonged life expectancy, albeit with co-morbidities and substantial disease burden. Curative therapy with allogeneic haematopoietic stem cell transplantation is advocated for suitable patients. The understanding of the pathogenesis of the disease is guiding therapeutic advances. Novel agents have shown efficacy in improving anaemia and transfusion burden, and initial results from gene therapy approaches are promising. Despite scientific developments, worldwide inequality in the access of health resources is a major concern, because most patients live in underserved areas.
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Affiliation(s)
- Antonis Kattamis
- Division of Paediatric Haematology-Oncology, First Department of Paediatrics, National and Kapodistrian University of Athens, Athens, Greece.
| | - Janet L Kwiatkowski
- Division of Haematology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Paediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yesim Aydinok
- Department of Paediatric Heamatology and Oncology, Ege University School of Medicine, Izmir, Turkey
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29
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Chauhan W, Shoaib S, Fatma R, Zaka‐ur‐Rab Z, Afzal M. β‐thalassemia, and the advent of new Interventions beyond Transfusion and Iron chelation. Br J Clin Pharmacol 2022; 88:3610-3626. [DOI: 10.1111/bcp.15343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/10/2022] [Accepted: 03/29/2022] [Indexed: 01/19/2023] Open
Affiliation(s)
- Waseem Chauhan
- Human Genetics and Toxicology Laboratory, Department of Zoology Aligarh Muslim University Aligarh India
| | - Shoaib Shoaib
- Department of Biochemistry, JNMC Aligarh Muslim University Aligarh India
| | - Rafat Fatma
- Human Genetics and Toxicology Laboratory, Department of Zoology Aligarh Muslim University Aligarh India
| | - Zeeba Zaka‐ur‐Rab
- Department of Pediatrics, JNMC Aligarh Muslim University Aligarh India
| | - Mohammad Afzal
- Human Genetics and Toxicology Laboratory, Department of Zoology Aligarh Muslim University Aligarh India
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30
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Rodgers BD, Ward CW. Myostatin/Activin Receptor Ligands in Muscle and the Development Status of Attenuating Drugs. Endocr Rev 2022; 43:329-365. [PMID: 34520530 PMCID: PMC8905337 DOI: 10.1210/endrev/bnab030] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Indexed: 02/07/2023]
Abstract
Muscle wasting disease indications are among the most debilitating and often deadly noncommunicable disease states. As a comorbidity, muscle wasting is associated with different neuromuscular diseases and myopathies, cancer, heart failure, chronic pulmonary and renal diseases, peripheral neuropathies, inflammatory disorders, and, of course, musculoskeletal injuries. Current treatment strategies are relatively ineffective and can at best only limit the rate of muscle degeneration. This includes nutritional supplementation and appetite stimulants as well as immunosuppressants capable of exacerbating muscle loss. Arguably, the most promising treatments in development attempt to disrupt myostatin and activin receptor signaling because these circulating factors are potent inhibitors of muscle growth and regulators of muscle progenitor cell differentiation. Indeed, several studies demonstrated the clinical potential of "inhibiting the inhibitors," increasing muscle cell protein synthesis, decreasing degradation, enhancing mitochondrial biogenesis, and preserving muscle function. Such changes can prevent muscle wasting in various disease animal models yet many drugs targeting this pathway failed during clinical trials, some from serious treatment-related adverse events and off-target interactions. More often, however, failures resulted from the inability to improve muscle function despite preserving muscle mass. Drugs still in development include antibodies and gene therapeutics, all with different targets and thus, safety, efficacy, and proposed use profiles. Each is unique in design and, if successful, could revolutionize the treatment of both acute and chronic muscle wasting. They could also be used in combination with other developing therapeutics for related muscle pathologies or even metabolic diseases.
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Affiliation(s)
| | - Christopher W Ward
- Department of Orthopedics and Center for Biomedical Engineering and Technology (BioMET), University of Maryland School of Medicine, Baltimore, MD, USA
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Novel histone deacetylase inhibitor CT-101 induces γ-globin gene expression in sickle erythroid progenitors with targeted epigenetic effects. Blood Cells Mol Dis 2022; 93:102626. [PMID: 34856533 PMCID: PMC9733664 DOI: 10.1016/j.bcmd.2021.102626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 12/13/2022]
Abstract
Induction of fetal hemoglobin (HbF) expression ameliorates the clinical severity and prolong survival in persons with sickle cell disease (SCD). Hydroxyurea (HU) is the only FDA-approved HbF inducer however, additional therapeutics that produce an additive effect in SCD are needed. To this end, development of potent Class I histone deacetylase inhibitors (HDACi) for HbF induction represents a rational molecularly targeted approach. In studies here, we evaluated CT-101, a novel Class I-restricted HDACi, a Largazole derivative, for pharmacodynamics, cytotoxicity, and targeted epigenetic effects. In SCD-derived erythroid progenitors, CT-101 induced HbF expression with additive activity in combination with HU. CT-101 preferentially activated γ-globin gene transcription, increased acetylated histone H3 levels, and conferred an open chromatin conformation in the γ-globin promoter. These data indicate CT-101 represents a strong potential candidate as a molecularly targeted inducer of HbF.
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Weidner H, Wobus M, Hofbauer LC, Rauner M, Platzbecker U. Luspatercept mitigates bone loss driven by myelodysplastic neoplasms and estrogen-deficiency in mice. Leukemia 2022; 36:2715-2718. [PMID: 36175549 PMCID: PMC9613459 DOI: 10.1038/s41375-022-01702-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/29/2022] [Accepted: 09/06/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Heike Weidner
- grid.4488.00000 0001 2111 7257 Department of Medicine III and Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Manja Wobus
- grid.4488.00000 0001 2111 7257Department of Medicine I, Technische Universität Dresden, Dresden, Germany
| | - Lorenz C. Hofbauer
- grid.4488.00000 0001 2111 7257 Department of Medicine III and Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany ,grid.7497.d0000 0004 0492 0584German Cancer Consortium (DKTK), partner site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martina Rauner
- grid.4488.00000 0001 2111 7257 Department of Medicine III and Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Uwe Platzbecker
- German Cancer Consortium (DKTK), partner site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Medical Clinic and Policlinic I, Hematology and Cellular Therapy, University Hospital Leipzig, Leipzig, Germany.
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Madan U, Bhasin H, Dewan P, Madan J. Improving Ineffective Erythropoiesis in Thalassemia: A Hope on the Horizon. Cureus 2021; 13:e18502. [PMID: 34754662 PMCID: PMC8567967 DOI: 10.7759/cureus.18502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 01/19/2023] Open
Abstract
Beta-thalassemia is an inherited hemoglobinopathy characterized by the impaired synthesis of beta-globin chains of hemoglobin leading to chronic hemolytic anemia. The mainstay of treatment for most patients remains regular blood transfusions and iron chelation. This conventional therapy has many limitations and challenges. Allogeneic hematopoietic stem cell transplant (HSCT) is the only available curative treatment but the availability of a suitable donor, financial constraints, and a need for specialist physicians can be limiting factors. Gene therapy is an upcoming curative therapeutic modality. An increased understanding of the underlying pathophysiology and molecular mechanisms of thalassemia has paved the way for novel pharmacological agents targeting ineffective erythropoiesis. These drugs act by decreasing transfusion requirements and hence decrease transfusion-related complications. The present review intends to provide an insight into the recent advances in pharmacological agents targeting ineffective erythropoiesis. Literature was searched and relevant articles evaluating newer drugs in thalassemia were collected from databases, including Pubmed, Scopus, Prospero, Clinicaltrials.gov, Google Scholar, and the Google search engine. We used the following keywords: thalassemia, novel, treatment, drugs, and ineffective erythropoiesis during the initial search. Relevant titles and abstracts were screened to choose relevant articles. Further, the full-text articles were retrieved and relevant cross-references were scanned to collect information for the present review.
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Affiliation(s)
- Ujjwal Madan
- Pediatrics, University College of Medical Sciences, Delhi, IND
| | - Himani Bhasin
- Pediatrics, University College of Medical Sciences, Delhi, IND
| | - Pooja Dewan
- Pediatrics, University College of Medical Sciences, Delhi, IND
| | - Jyotsna Madan
- Pathology, Super Speciality Pediatric Hospital and Post Graduate Teaching Institute, Noida, Uttar Pradesh, IND
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Musallam KM, Bou‐Fakhredin R, Cappellini MD, Taher AT. 2021 update on clinical trials in β-thalassemia. Am J Hematol 2021; 96:1518-1531. [PMID: 34347889 DOI: 10.1002/ajh.26316] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 01/19/2023]
Abstract
The treatment landscape for patients with β-thalassemia is witnessing a swift evolution, yet several unmet needs continue to persist. Patients with transfusion-dependent β-thalassemia (TDT) primarily rely on regular transfusion and iron chelation therapy, which can be associated with considerable treatment burden and cost. Patients with non-transfusion-dependent β-thalassemia (NTDT) are also at risk of significant morbidity due to the underlying anemia and iron overload, but treatment options in this patient subgroup are limited. In this review, we provide updates on clinical trials of novel therapies targeting the underlying pathology in β-thalassemia, including the α/non-α-globin chain imbalance, ineffective erythropoiesis, and iron dysregulation.
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Affiliation(s)
- Khaled M. Musallam
- Thalassemia Center, Burjeel Medical City Abu Dhabi United Arab Emirates
- International Network of Hematology London UK
| | - Rayan Bou‐Fakhredin
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community University of Milan, Ca’ Granda Foundation IRCCS Maggiore Policlinico Hospital Milan Italy
| | - Ali T. Taher
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
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De Simone G, Quattrocchi A, Mancini B, di Masi A, Nervi C, Ascenzi P. Thalassemias: From gene to therapy. Mol Aspects Med 2021; 84:101028. [PMID: 34649720 DOI: 10.1016/j.mam.2021.101028] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/19/2021] [Indexed: 12/26/2022]
Abstract
Thalassemias (α, β, γ, δ, δβ, and εγδβ) are the most common genetic disorders worldwide and constitute a heterogeneous group of hereditary diseases characterized by the deficient synthesis of one or more hemoglobin (Hb) chain(s). This leads to the accumulation of unstable non-thalassemic Hb chains, which precipitate and cause intramedullary destruction of erythroid precursors and premature lysis of red blood cells (RBC) in the peripheral blood. Non-thalassemic Hbs display high oxygen affinity and no cooperativity. Thalassemias result from many different genetic and molecular defects leading to either severe or clinically silent hematologic phenotypes. Thalassemias α and β are particularly diffused in the regions spanning from the Mediterranean basin through the Middle East, Indian subcontinent, Burma, Southeast Asia, Melanesia, and the Pacific Islands, whereas δβ-thalassemia is prevalent in some Mediterranean regions including Italy, Greece, and Turkey. Although in the world thalassemia and malaria areas overlap apparently, the RBC protection against malaria parasites is openly debated. Here, we provide an overview of the historical, geographic, genetic, structural, and molecular pathophysiological aspects of thalassemias. Moreover, attention has been paid to molecular and epigenetic pathways regulating globin gene expression and globin switching. Challenges of conventional standard treatments, including RBC transfusions and iron chelation therapy, splenectomy and hematopoietic stem cell transplantation from normal donors are reported. Finally, the progress made by rapidly evolving fields of gene therapy and gene editing strategies, already in pre-clinical and clinical evaluation, and future challenges as novel curative treatments for thalassemia are discussed.
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Affiliation(s)
- Giovanna De Simone
- Dipartimento di Scienze, Università Roma Tre, Viale Guglielmo Marconi 446, 00146, Roma, Italy
| | - Alberto Quattrocchi
- Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche, Facoltà di Farmacia e Medicina, "Sapienza" Università di Roma, Corso della Repubblica, 79, 04100, Latina, Italy
| | - Benedetta Mancini
- Dipartimento di Scienze, Università Roma Tre, Viale Guglielmo Marconi 446, 00146, Roma, Italy
| | - Alessandra di Masi
- Dipartimento di Scienze, Università Roma Tre, Viale Guglielmo Marconi 446, 00146, Roma, Italy
| | - Clara Nervi
- Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche, Facoltà di Farmacia e Medicina, "Sapienza" Università di Roma, Corso della Repubblica, 79, 04100, Latina, Italy.
| | - Paolo Ascenzi
- Dipartimento di Scienze, Università Roma Tre, Viale Guglielmo Marconi 446, 00146, Roma, Italy; Accademia Nazionale dei Lincei, Via della Lungara 10, 00165, Roma, Italy.
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Colucci S, Altamura S, Marques O, Dropmann A, Horvat NK, Müdder K, Hammad S, Dooley S, Muckenthaler MU. Liver Sinusoidal Endothelial Cells Suppress Bone Morphogenetic Protein 2 Production in Response to TGFβ Pathway Activation. Hepatology 2021; 74:2186-2200. [PMID: 33982327 DOI: 10.1002/hep.31900] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/15/2021] [Accepted: 05/04/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS TGFβ/bone morphogenetic protein (BMP) signaling in the liver plays a critical role in liver disease. Growth factors, such as BMP2, BMP6, and TGFβ1, are released from LSECs and signal in a paracrine manner to hepatocytes and hepatic stellate cells to control systemic iron homeostasis and fibrotic processes, respectively. The misregulation of the TGFβ/BMP pathway affects expression of the iron-regulated hormone hepcidin, causing frequent iron overload and deficiency diseases. However, whether LSEC-secreted factors can act in an autocrine manner to maintain liver homeostasis has not been addressed so far. APPROACH AND RESULTS We analyzed publicly available RNA-sequencing data of mouse LSECs for ligand-receptor interactions and identified members of the TGFβ family (BMP2, BMP6, and TGFβ1) as ligands with the highest expression levels in LSECs that may signal in an autocrine manner. We next tested the soluble factors identified through in silico analysis in optimized murine LSEC primary cultures and mice. Exposure of murine LSEC primary cultures to these ligands shows that autocrine responses to BMP2 and BMP6 are blocked despite high expression levels of the required receptor complexes partially involving the inhibitor FK-506-binding protein 12. By contrast, LSECs respond efficiently to TGFβ1 treatment, which causes reduced expression of BMP2 through activation of activin receptor-like kinase 5. CONCLUSIONS These findings reveal that TGFβ1 signaling is functionally interlinked with BMP signaling in LSECs, suggesting druggable targets for the treatment of iron overload diseases associated with deficiency of the BMP2-regulated hormone hepcidin, such as hereditary hemochromatosis, β-thalassemia, and chronic liver diseases.
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Affiliation(s)
- Silvia Colucci
- Department of Pediatric Hematology, Oncology and Immunology, University of Heidelberg, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany
| | - Sandro Altamura
- Department of Pediatric Hematology, Oncology and Immunology, University of Heidelberg, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany
| | - Oriana Marques
- Department of Pediatric Hematology, Oncology and Immunology, University of Heidelberg, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany
| | - Anne Dropmann
- Section Molecular Hepatology, Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Natalie K Horvat
- Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany.,European Molecular Biology Laboratory (EMBL), Heidelberg, Germany
| | - Katja Müdder
- Department of Pediatric Hematology, Oncology and Immunology, University of Heidelberg, Heidelberg, Germany
| | - Seddik Hammad
- Section Molecular Hepatology, Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Department of Forensic and Toxicology, Faculty of Veterinary Medicine, South Valley University, Qena, Egypt
| | - Steven Dooley
- Section Molecular Hepatology, Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martina U Muckenthaler
- Department of Pediatric Hematology, Oncology and Immunology, University of Heidelberg, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany
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Functionally diverse heteromeric traps for ligands of the transforming growth factor-β superfamily. Sci Rep 2021; 11:18341. [PMID: 34526551 PMCID: PMC8443706 DOI: 10.1038/s41598-021-97203-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/18/2021] [Indexed: 01/19/2023] Open
Abstract
Ligands of the transforming growth factor-β (TGF-β) superfamily are important targets for therapeutic intervention but present challenges because they signal combinatorially and exhibit overlapping activities in vivo. To obtain agents capable of sequestering multiple TGF-β superfamily ligands with novel selectivity, we generated soluble, heterodimeric ligand traps by pairing the extracellular domain (ECD) of the native activin receptor type IIB (ActRIIB) alternately with the ECDs of native type I receptors activin receptor-like kinase 4 (ALK4), ALK7, or ALK3. Systematic analysis of these heterodimeric constructs by surface plasmon resonance, and comparison with their homodimeric counterparts, revealed that each type I receptor partner confers a distinct ligand-binding profile to the heterodimeric construct. Additional characterization in cell-based reporter gene assays confirmed that the heterodimeric constructs possessed different profiles of signaling inhibition in vitro, which translated into altered patterns of pharmacological activity when constructs were administered systemically to wild-type mice. Our results detail a versatile platform for the modular recombination of naturally occurring receptor domains, giving rise to inhibitory ligand traps that could aid in defining the physiological roles of TGF-β ligand sets or be directed therapeutically to human diseases arising from dysregulated TGF-β superfamily signaling.
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Suriyun T, Kaewsakulthong W, Khamphikham P, Chumchuen S, Hongeng S, Fucharoen S, Sripichai O. Association of the Degree of Erythroid Expansion and Maturation Arrest with the Clinical Severity of β0-Thalassemia/Hemoglobin E Patients. Acta Haematol 2021; 144:660-671. [PMID: 34535581 DOI: 10.1159/000518310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION β-Thalassemia/hemoglobin E represents one-half of all the clinically severe β-thalassemias worldwide. Despite similar genetic backgrounds, patients show clinical heterogeneity ranging from nearly asymptomatic to transfusion-dependent thalassemia. The underlying disease modifying factors remain largely obscure. METHODS To elucidate the correlation between ineffective erythropoiesis and β0-thalassemia/hemoglobin E (HbE) disease severity, in vitro culture of erythroid cells derived from patients with different clinical symptoms was established. Cell proliferation, viability, and differentiation were investigated. To identify potential molecular mechanisms leading to the arrested erythroid maturation, the expression levels of erythropoiesis modifying factors were measured. RESULTS The β0-thalassemia/HbE cells exhibited enhanced proliferation, limited differentiation, and impaired erythroid terminal maturation but did not show accelerated erythroblast differentiation and increased cell death. Erythroblasts derived from mild patients showed the highest proliferation rate with a faster cell division time, while erythroblasts derived from severe patients displayed extremely delayed erythroid maturation. Downregulation of growth differentiation factor 11 and FOXO3a was observed in mild β0-thalassemia/HbE erythroblasts, while upregulation of heat shock protein 70 and activin receptor 2A was revealed in severe erythroblasts. DISCUSSION/CONCLUSION The degree of erythroid expansion and maturation arrest contributes to the severity of β0-thalassemia/HbE patients, accounting for the disease heterogeneity. The findings suggest a restoration of erythroid maturation as a promising targeted therapy for severe patients.
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Affiliation(s)
- Thunwarat Suriyun
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Woratree Kaewsakulthong
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pinyaphat Khamphikham
- Institute of Molecular Biosciences, Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Nakhonpathom, Thailand
- Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Sukanya Chumchuen
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suradej Hongeng
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suthat Fucharoen
- Institute of Molecular Biosciences, Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Nakhonpathom, Thailand
| | - Orapan Sripichai
- Institute of Molecular Biosciences, Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Nakhonpathom, Thailand
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
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Taher AT, Bou-Fakhredin R, Kattamis A, Viprakasit V, Cappellini MD. Improving outcomes and quality of life for patients with transfusion-dependent β-thalassemia: recommendations for best clinical practice and the use of novel treatment strategies. Expert Rev Hematol 2021; 14:897-909. [PMID: 34493145 DOI: 10.1080/17474086.2021.1977116] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION β-thalassemia is one of the most common inherited monogenic diseases. Many patients are dependent on a lifetime of red blood cell (RBC) transfusions and iron chelation therapy. Although treatments have a significant impact on quality of life (QoL), life expectancy, and long-term health outcomes have improved in recent decades through safer RBC transfusion practices and better iron chelation strategies. Advances in the understanding of the pathology of β-thalassemia have led to the development of new treatment options that have the potential to reduce the RBC transfusion burden in patients with transfusion-dependent (TD) β-thalassemia and improve QoL. AREAS COVERED This review provides an overview of currently available treatments for patients with TD β-thalassemia, highlighting QoL issues, and providing an update on current clinical experience plus important practical points for two new treatments available for TD β-thalassemia: betibeglogene autotemcel (beti-cel) gene therapy and the erythroid maturation agent luspatercept, an activin ligand trap. EXPERT OPINION Approved therapies, including curative gene therapies and supportive treatments such as luspatercept, have the potential to reduce RBC transfusion burden, and improve clinical outcomes and QoL in patients with TD β-thalassemia. Cost of treatment is, however, likely to be a significant barrier for payors and patients.
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Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Vip Viprakasit
- Siriraj Center of Excellence on Advanced Gene and Cellular Therapy (Si-COE-AGCT) & Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Sinha S, Pereira-Reis J, Guerra A, Rivella S, Duarte D. The Role of Iron in Benign and Malignant Hematopoiesis. Antioxid Redox Signal 2021; 35:415-432. [PMID: 33231101 PMCID: PMC8328043 DOI: 10.1089/ars.2020.8155] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/26/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022]
Abstract
Significance: Iron is an essential element required for sustaining a normal healthy life. However, an excess amount of iron in the bloodstream and tissue generates toxic hydroxyl radicals through Fenton reactions. Henceforth, a balance in iron concentration is extremely important to maintain cellular homeostasis in both normal hematopoiesis and erythropoiesis. Iron deficiency or iron overload can impact hematopoiesis and is associated with many hematological diseases. Recent Advances: The mechanisms of action of key iron regulators such as erythroferrone and the discovery of new drugs, such as ACE-536/luspatercept, are of potential interest to treat hematological disorders, such as β-thalassemia. New therapies targeting inflammation-induced ineffective erythropoiesis are also in progress. Furthermore, emerging evidences support differential interactions between iron and its cellular antioxidant responses of hematopoietic and neighboring stromal cells. Both iron and its systemic regulator, such as hepcidin, play a significant role in regulating erythropoiesis. Critical Issues: Significant pre-clinical studies are on the way and new drugs targeting iron metabolism have been recently approved or are undergoing clinical trials to treat pathological conditions with impaired erythropoiesis such as myelodysplastic syndromes or β-thalassemia. Future Directions: Future studies should explore how iron regulates hematopoiesis in both benign and malignant conditions. Antioxid. Redox Signal. 35, 415-432.
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Affiliation(s)
- Sayantani Sinha
- Division of Hematology, Department of Pediatrics, The Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Joana Pereira-Reis
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Porto, Portugal
| | - Amaliris Guerra
- Division of Hematology, Department of Pediatrics, The Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Stefano Rivella
- Division of Hematology, Department of Pediatrics, The Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cell and Molecular Biology Affinity Group (CAMB), University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
- Penn Center for Musculoskeletal Disorders, The Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Delfim Duarte
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Porto, Portugal
- Department of Onco-Hematology, Instituto Português de Oncologia (IPO), Porto, Portugal
- Unit of Biochemistry, Department of Biomedicine, Faculdade de Medicina da Universidade do Porto (FMUP), Porto, Portugal
- Porto Comprehensive Cancer Center (P.CCC), Porto, Portugal
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Taher AT, Cappellini MD. Luspatercept for β-thalassemia: beyond red blood cell transfusions. Expert Opin Biol Ther 2021; 21:1363-1371. [PMID: 34404288 DOI: 10.1080/14712598.2021.1968825] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Red blood cell transfusions and iron chelation therapy are the cornerstone of treatment for β-thalassemia, with allogeneic hematopoietic stem cell transplantation and gene therapy offering further disease-management options for eligible patients. With up to 90% of severe cases of β-thalassemia occurring in resource-constrained countries, and estimates indicating that 22,500 deaths occur annually as a direct consequence of undertransfusion, provision of adequate treatment remains a major issue. AREAS COVERED In this review, we provide an overview of luspatercept, a first-in-class erythroid maturation agent, and present the available clinical data related to the treatment of β-thalassemia. EXPERT OPINION The recent approval of luspatercept offers a new, long-term therapeutic option for adult patients with transfusion-dependent β-thalassemia to reduce red blood cell transfusion burden, anemia, and iron overload.
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Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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42
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Trivedi G, Inoue D, Zhang L. Targeting low-risk myelodysplastic syndrome with novel therapeutic strategies. Trends Mol Med 2021; 27:990-999. [PMID: 34257007 DOI: 10.1016/j.molmed.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 11/26/2022]
Abstract
Myelodysplastic syndrome (MDS) is a group of hematopoietic disorders with limited treatment options. Anemia is a common symptom in MDS, and although erythropoiesis-stimulating agents such as erythropoietin, lenalidomide, and luspatercept are available to treat anemia, many MDS patients do not respond to these first-line therapies. Therefore, alternative drug development strategies are needed to improve therapeutic efficacy. Splicing modulators to correct splicing-related defects have shown promising results in clinical trials. Targeting differentiation of early erythroid progenitors to increase the erythroid output in MDS is another novel approach, which has shown encouraging results at the pre-clinical stage. Together, these therapeutic strategies provide new avenues to target MDS symptoms untreatable previously.
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Affiliation(s)
- Gaurang Trivedi
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA; Genetics Program, Stony Brook University, Stony Brook, NY 11794, USA
| | - Daichi Inoue
- Department of Hematology-Oncology, Institute of Biomedical Research and Innovation, Foundation for Biomedical Research and Innovation at Kobe, Kobe 650-0047, Japan
| | - Lingbo Zhang
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA.
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Ledesma-Colunga MG, Weidner H, Vujic Spasic M, Hofbauer LC, Baschant U, Rauner M. Shaping the bone through iron and iron-related proteins. Semin Hematol 2021; 58:188-200. [PMID: 34389111 DOI: 10.1053/j.seminhematol.2021.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/18/2021] [Accepted: 06/08/2021] [Indexed: 01/04/2023]
Abstract
Well-controlled iron levels are indispensable for health. Iron deficiency is the most common cause of anemia, whereas iron overload, either hereditary or secondary due to disorders of ineffective erythropoiesis, causes widespread organ failure. Bone is particularly sensitive to fluctuations in systemic iron levels as both iron deficiency and overload are associated with low bone mineral density and fragility. Recent studies have shown that not only iron itself, but also iron-regulatory proteins that are mutated in hereditary hemochromatosis can control bone mass. This review will summarize the current knowledge on the effects of iron on bone homeostasis and bone cell activities, and on the role of proteins that regulate iron homeostasis, i.e. hemochromatosis proteins and proteins of the bone morphogenetic protein pathway, on bone remodeling. As disorders of iron homeostasis are closely linked to bone fragility, deeper insights into common regulatory mechanisms may provide new opportunities to concurrently treat disorders affecting iron homeostasis and bone.
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Affiliation(s)
- Maria G Ledesma-Colunga
- Divisions of Endocrinology and Molecular Bone Biology, Department of Medicine III & University Center for Healty Aging, Technische Universität Dresden, Dresden, Germany
| | - Heike Weidner
- Divisions of Endocrinology and Molecular Bone Biology, Department of Medicine III & University Center for Healty Aging, Technische Universität Dresden, Dresden, Germany
| | - Maja Vujic Spasic
- Institute of Comparative Molecular Endocrinology, Ulm University, Ulm, Germany
| | - Lorenz C Hofbauer
- Divisions of Endocrinology and Molecular Bone Biology, Department of Medicine III & University Center for Healty Aging, Technische Universität Dresden, Dresden, Germany
| | - Ulrike Baschant
- Divisions of Endocrinology and Molecular Bone Biology, Department of Medicine III & University Center for Healty Aging, Technische Universität Dresden, Dresden, Germany
| | - Martina Rauner
- Divisions of Endocrinology and Molecular Bone Biology, Department of Medicine III & University Center for Healty Aging, Technische Universität Dresden, Dresden, Germany.
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Makis A, Voskaridou E, Papassotiriou I, Hatzimichael E. Novel Therapeutic Advances in β-Thalassemia. BIOLOGY 2021; 10:biology10060546. [PMID: 34207028 PMCID: PMC8235056 DOI: 10.3390/biology10060546] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 01/19/2023]
Abstract
Simple Summary Beta-thalassemia (β-thalassemia) is an autosomal recessive inherited disorder that causes decreased production of hemoglobin. Ineffective erythropoiesis and excess iron deposition are the most significant pathophysiological problems. Chronic red blood cell transfusions along with control of iron overload are the main principles of treatment. Yet, the patients have a problematic quality of life. Recently, novel therapies have emerged based on better knowledge of the pathophysiology of the disease. Aiming at ineffective erythropoiesis through the TGF-β ligand traps, such as luspatercept, has been shown to reduce the transfusion burden. Therapeutic approaches aiming at the iron metabolism mechanisms as well as the pathway of the production of erythroid cyclic guanosine monophosphate are being used in clinical trials with encouraging results. Significant improvements in the technique of hemopoietic stem cell transplantation have been accomplished, with a focus on the improvement of the conditioning regimen and the donor selection. Gene therapy has exhibited remarkable advances using lentiviral β-globin gene insertion techniques or gene editing platforms that target the suppression of γ-globin repressors. All these approaches will have a positive result in the quality of life of thalassemia patients. Abstract The main characteristic of the pathophysiology of β-thalassemia is reduced β-globin chain production. The inevitable imbalance in the α/β-globin ratio and α-globin accumulation lead to oxidative stress in the erythroid lineage, apoptosis, and ineffective erythropoiesis. The result is compensatory hematopoietic expansion and impaired hepcidin production that causes increased intestinal iron absorption and progressive iron overload. Chronic hemolysis and red blood cell transfusions also contribute to iron tissue deposition. A better understanding of the underlying mechanisms led to the detection of new curative or “disease-modifying” therapeutic options. Substantial evolvement has been made in allogeneic hematopoietic stem cell transplantation with current clinical trials investigating new condition regimens as well as different donors and stem cell source options. Gene therapy has also moved forward, and phase 2 clinical trials with the use of β-globin insertion techniques have recently been successfully completed leading to approval for use in transfusion-dependent patients. Genetic and epigenetic manipulation of the γ- or β-globin gene have entered the clinical trial setting. Agents such as TGF-β ligand traps and pyruvate kinase activators, which reduce the ineffective erythropoiesis, have been tested in clinical trials with favorable results. One TGF-β ligand trap, luspatercept, has been approved for use in adults with transfusion-dependent β-thalassemia. The induction of HbF with the phosphodiesterase 9 inhibitor IMR-687, which increase cyclic guanosine monophosphate, is currently being tested. Another therapeutic approach is to target the dysregulation of iron homeostasis, using, for example, hepcidin agonists (inhibitors of TMPRSS6 and minihepcidins) or ferroportin inhibitors (VIT-2763). This review provides an update on the novel therapeutic options that are presently in development at the clinical level in β-thalassemia.
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Affiliation(s)
- Alexandros Makis
- Department of Pediatrics, Faculty of Medicine, University of Ioannina, Stavros Niarchos Avenue, 45110 Ioannina, Greece
- Correspondence: ; Tel.: +30-2651099793
| | - Ersi Voskaridou
- Centre of Excellence in Rare Haematological Diseases-Haemoglobinopathies, “Laikon” General Hospital, 11527 Athens, Greece;
| | - Ioannis Papassotiriou
- Department of Clinical Biochemistry, “Aghia Sophia” Children’s Hospital, 11527 Athens, Greece;
| | - Eleftheria Hatzimichael
- Department of Hematology, Faculty of Medicine, University of Ioannina, Stavros Niarchos Avenue, 45110 Ioannina, Greece;
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Hu C, Yan Y, Fu C, Ding J, Li T, Wang S, Fang L. Effects of miR‑210‑3p on the erythroid differentiation of K562 cells under hypoxia. Mol Med Rep 2021; 24:563. [PMID: 34109429 PMCID: PMC8201459 DOI: 10.3892/mmr.2021.12202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 05/20/2021] [Indexed: 11/08/2022] Open
Abstract
GATA binding protein 1 (GATA-1) is one of the most important hematopoietic transcription factors in the production of blood cells, such as platelets, eosinophils, mast cells and erythrocytes. GATA-1 regulates the participation of microRNA (miRNAs/miRs) in erythroid differentiation under normoxia. However, GATA-1 expression and the regulation of miR-210-3p in the context of erythroid differentiation under hypoxia remain unknown. The present study examined the expression levels of GATA-1 and miR-210-3p in the model of erythroid differentiation in K562 cells under hypoxia, and determined the effects of GATA-1, miR-210-3p and SMAD2 on erythroid differentiation through lentivirus transfection experiments. The present study detected increased GATA-1 expression under hypoxia. Moreover, miR-210-3p was identified as a positive regulator of erythroid differentiation, which was upregulated both during erythroid differentiation and in GATA-1 overexpression experiments under hypoxia. Importantly, in the K562 cell model of erythroid differentiation under hypoxia, miR-210-3p was upregulated in a GATA-1-dependent manner. Using a double luciferase reporter assay, miR-210-3p was identified as a downstream target of GATA-1-mediated regulation of erythropoiesis. Gain- or loss-of-function analysis of miR-210-3p identified its importance in erythroid differentiation. Furthermore, it was found that SMAD2 may be a downstream target gene for miR-210-3p. Bioinformatics predictions suggested that SMAD2 mediated miR-210-3p-induced regulation of erythroid differentiation. Collectively, the present study provides novel insights into the miRNA regulation of erythroid differentiation.
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Affiliation(s)
- Caiyan Hu
- Department of Biochemistry, Qing Hai University Medical College, Xining, Qinghai 810000, P.R. China
| | - Yupeng Yan
- Department of Biochemistry, Qing Hai University Medical College, Xining, Qinghai 810000, P.R. China
| | - Chengbing Fu
- Department of Biochemistry, Qing Hai University Medical College, Xining, Qinghai 810000, P.R. China
| | - Jin Ding
- Department of Biochemistry, Qing Hai University Medical College, Xining, Qinghai 810000, P.R. China
| | - Tiantian Li
- Department of Biochemistry, Qing Hai University Medical College, Xining, Qinghai 810000, P.R. China
| | - Shuqiong Wang
- Department of Biochemistry, Qing Hai University Medical College, Xining, Qinghai 810000, P.R. China
| | - Liu Fang
- Department of Biochemistry, Qing Hai University Medical College, Xining, Qinghai 810000, P.R. China
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The use of luspatercept for thalassemia in adults. Blood Adv 2021; 5:326-333. [PMID: 33570654 DOI: 10.1182/bloodadvances.2020002725] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/01/2020] [Indexed: 01/19/2023] Open
Abstract
Luspatercept is an activin receptor ligand trap that has been shown to enhance late-stage erythropoiesis in animal models of β-thalassemia. A multicenter, international, phase 2 dose-finding study was initiated in adult patients with β-thalassemia, either non-transfusion-dependent thalassemia (NTDT) or transfusion-dependent thalassemia (TDT). Positive results of the phase 2 study paved the way to a randomized phase 3 clinical trial (BELIEVE) to assess the efficacy and safety of luspatercept. The BELIEVE trial is a randomized, double-blind, placebo-controlled phase 3 trial. Three hundred thirty-six patients aged ≥18 years with TDT (regularly transfused, 6-20 red blood cell units within 24 weeks before randomization) were included in the trial. Patients received luspatercept or placebo subcutaneously every 21 days for ≥48 weeks and best supportive care. Forty-eight of 224 patients (21.4%) in the luspatercept group achieved the primary end points (≥33% reduction in transfusion burden) compared with those in the placebo group (4.5%; P < .001). Moreover, more patients had a ≥33% reduction in transfusion burden during any rolling 12-week interval (70.5% vs 29.5%) or any 24-week interval (41.1% vs 2.7%) with luspatercept than with the placebo. Transfusion independence was achieved by 11% of patients in the luspatercept group. Transient adverse events were more frequent with luspatercept than with placebo, but were manageable. Luspatercept was approved by the US Food and Drug Administration in 2019 and by the European Medicines Agency in 2020. The luspatercept trial is registered on www.clinicaltrials.gov at #NCT01749540 and the BELIEVE trial at #NCT02604433.
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Kang C, Syed YY. Luspatercept: A Review in Transfusion-Dependent Anaemia due to Myelodysplastic Syndromes or β-Thalassaemia. Drugs 2021; 81:945-952. [PMID: 33970460 DOI: 10.1007/s40265-021-01527-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 01/19/2023]
Abstract
Luspatercept (Reblozyl®), a first-in-class erythroid maturation agent, is approved in several countries worldwide for the treatment of adults with transfusion-dependent anaemia due to myelodysplastic syndromes (MDS), who have failed prior erythropoiesis-stimulating therapy, or β-thalassaemia. In pivotal, placebo-controlled, phase III trials, subcutaneous luspatercept significantly reduced red blood cell (RBC) transfusion requirements in patients with MDS or β-thalassaemia. Luspatercept had a generally manageable tolerability profile in clinical trials. Adverse events of special interest include thromboembolic events, hypertension and bone pain. Thus, luspatercept is an emerging treatment option in adults with transfusion-dependent anaemia due to MDS or β-thalassaemia.
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Affiliation(s)
- Connie Kang
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Yahiya Y Syed
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
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Motta I, Bou-Fakhredin R, Taher AT, Cappellini MD. Beta Thalassemia: New Therapeutic Options Beyond Transfusion and Iron Chelation. Drugs 2021; 80:1053-1063. [PMID: 32557398 PMCID: PMC7299245 DOI: 10.1007/s40265-020-01341-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hemoglobinopathies are among the most common monogenic diseases worldwide. Approximately 1–5% of the global population are carriers for a genetic thalassemia mutation. The thalassemias are characterized by autosomal recessive inherited defects in the production of hemoglobin. They are highly prevalent in the Mediterranean, Middle East, Indian subcontinent, and East and Southeast Asia. Due to recent migrations, however, the thalassemias are now becoming more common in Europe and North America, making this disease a global health concern. Currently available conventional therapies in thalassemia have many challenges and limitations. A better understanding of the pathophysiology of β-thalassemia in addition to key developments in optimizing transfusion programs and iron-chelation therapy has led to an increase in the life span of thalassemia patients and paved the way for new therapeutic strategies. These can be classified into three categories based on their efforts to address different features of the underlying pathophysiology of β-thalassemia: correction of the globin chain imbalance, addressing ineffective erythropoiesis, and improving iron overload. In this review, we provide an overview of the novel therapeutic approaches that are currently in development for β-thalassemia.
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Affiliation(s)
- Irene Motta
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rayan Bou-Fakhredin
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy. .,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Darvishi-Khezri H, Karami H. Luspatercept: A Gigantic Step in the Treatment of Transfusion-Dependent β-Thalassemia Patients-a Quick Review. Adv Ther 2021; 38:1732-1745. [PMID: 33661441 DOI: 10.1007/s12325-021-01663-4] [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: 01/12/2021] [Accepted: 02/10/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Some studies have indicated that the use of luspatercept may be a novel and efficient treatment for β-thalassemia patients. In this article, we aimed to review the current evidence related to luspatercept prescription and its clinical effectiveness in patients with β-thalassemia. METHODS PubMed, Web of Science, Scopus, Trip and CENTRAL were searched up to June 2020. The inclusion criteria were English-language articles that studied the effects of luspatercept on improving anemia severity in patients with β-thalassemia in a clinical setting. RESULTS The search strategy yielded 273 potentially relevant articles. After searching the databases, scanning of titles, abstracts and full texts for relevancy was performed to identify suitable articles. A total of 77 articles were confirmed for full text analysis. The estimated number of patients needed to treat (NNT) for luspatercept treatment, using data derived from conducted clinical trials, according to a reduction in transfusion need of ≥ 33% or ≥ 50 from baseline, during week 13-24/week 37-48/any 12- and 24-week intervals as outcomes, was 3-5 in patients with β-thalassemia. CONCLUSION Based on the conducted studies, the effectiveness of luspatercept on transfusion burden and hemoglobin levels was outstanding in β-thalassemia patients. Further large and well-designed clinical studies are needed to identify any unforeseen complications subsequent to use of luspatercept, particularly when used with other treatments with potentially serious adverse effects such as anti-osteoporotic and iron chelator agents.
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Musallam KM, Rivella S, Taher AT. Management of non-transfusion-dependent β-thalassemia (NTDT): The next 5 years. Am J Hematol 2021; 96:E57-E59. [PMID: 33219704 DOI: 10.1002/ajh.26055] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | - Stefano Rivella
- Department of Pediatrics, Division of Hematology; Raymond G. Perelman Center for Cellular and Molecular Therapeutics; Abramson Research Center at The Childrenʼs Hospital of Philadelphia (CHOP); Cell and Molecular Biology Affinity Group (CAMB), Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Ali T. Taher
- Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
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