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Al-Samkari H, Albitar HA, Olitsky SE, Clancy MS, Iyer VN. An international survey to evaluate systemic bevacizumab for chronic bleeding in hereditary haemorrhagic telangiectasia. Haemophilia 2020; 26:1038-1045. [PMID: 32432841 DOI: 10.1111/hae.14034] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 02/15/2020] [Accepted: 04/27/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Systemic bevacizumab is a novel targeted therapy for severe epistaxis and chronic gastrointestinal bleeding in hereditary haemorrhagic telangiectasia (HHT), but published data are very limited. AIM We conducted a survey-based study to characterize current treatment practices and physician-reported safety and effectiveness of systemic bevacizumab for bleeding in (HHT). METHODS A 27-item survey was sent to physician centre directors of 31 International HHT Centers of Excellence. RESULTS Response rate was 84%. Approximately half of centres had treated >10 HHT patients with systemic bevacizumab for chronic bleeding for a total of 291 patients treated. All centres utilize a 5 mg/kg dose for induction treatment and most administer six doses (range, 4-8) every 2 weeks. However, maintenance regimens varied considerably between centres. Bevacizumab was highly effective, with 86% reporting significant (>50%) improvement in GI bleeding and/or epistaxis and haemoglobin rise in most patients treated with bevacizumab; 52% reported haemoglobin normalization in most patients. All centres reported adverse event rates <30% and two-thirds of centres reported adverse event rates <10%. Discontinuation for adverse events or inefficacy was rare. Bleeding severity thresholds for initiation of bevacizumab were highly variable, and it is typically administered by haematologists (76% of centres). Two-thirds of centres reported obtaining insurance approval for bevacizumab for most or all patients but 48% reported difficulty in obtaining coverage. CONCLUSION Systemic bevacizumab is widely used to treat bleeding in HHT with excellent physician-reported effectiveness and safety. There is considerable variation in maintenance treatment practices and thresholds for initiation of bevacizumab among HHT centres.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hasan A Albitar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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Droege F, Pylaeva E, Siakaeva E, Bordbari S, Spyra I, Thangavelu K, Lueb C, Domnich M, Lang S, Geisthoff U, Jablonska J. Impaired Release of Neutrophil Extracellular Traps and Anemia-Associated T Cell Deficiency in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2020; 9:jcm9030767. [PMID: 32178330 PMCID: PMC7141391 DOI: 10.3390/jcm9030767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/22/2020] [Accepted: 03/08/2020] [Indexed: 12/12/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is characterized by mucocutaneous telangiectases and visceral vascular malformations. Individuals suffering from HHT have a significantly increased risk of bacterial infections, but the mechanisms involved in this are not clear. White blood cell subpopulations were estimated with flow cytometry in 79 patients with HHT and 45 healthy individuals, and association with clinicopathological status was assessed. A prominent decrease in absolute numbers of T cells in HHT was revealed (0.7 (0.5-1.1) vs. 1.3 (0.8-1.6), 106/mL, p < 0.05), and in multivariate regression analysis, hemoglobin level was associated with lymphopenia (OR = 0.625, 95% CI: 0.417-0.937, p < 0.05). Although no changes in absolute numbers of neutrophils and monocytes were observed, we revealed a significant impairment of neutrophil antibacterial functions in HHT (n = 9), compared to healthy individuals (n = 7), in vitro. The release of neutrophil extracellular traps (NETs) against Pseudomonas aeruginosa MOI10 was significantly suppressed in HHT (mean area per cell, mm2: 76 (70-92) vs. 121 (97-128), p < 0.05), due to impaired filamentous actin organization (% of positive cells: 69 (59-77) vs. 92 (88-94), p < 0.05). To conclude, this study reveals the categories of patients with HHT that are prone to immunosuppression and require careful monitoring, and suggests a potential therapeutic strategy based on the functional activation of neutrophils.
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Affiliation(s)
- Freya Droege
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (C.L.); (S.L.)
- Correspondence: ; Tel.: +49-201-723-85832; Fax: +49-201-723-1416
| | - Ekaterina Pylaeva
- Translational Oncology, Department of Otorhinolaryngology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (E.P.); (S.B.); (I.S.); (M.D.); (J.J.)
| | - Elena Siakaeva
- Translational Oncology, Department of Otorhinolaryngology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (E.P.); (S.B.); (I.S.); (M.D.); (J.J.)
| | - Sharareh Bordbari
- Translational Oncology, Department of Otorhinolaryngology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (E.P.); (S.B.); (I.S.); (M.D.); (J.J.)
| | - Ilona Spyra
- Translational Oncology, Department of Otorhinolaryngology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (E.P.); (S.B.); (I.S.); (M.D.); (J.J.)
| | - Kruthika Thangavelu
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Marburg, University of Gießen and Marburg, Baldingerstrasse, 35042 Marburg, Germany; (K.T.); (U.G.)
| | - Carolin Lueb
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (C.L.); (S.L.)
| | - Maksim Domnich
- Translational Oncology, Department of Otorhinolaryngology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (E.P.); (S.B.); (I.S.); (M.D.); (J.J.)
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (C.L.); (S.L.)
| | - Urban Geisthoff
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Marburg, University of Gießen and Marburg, Baldingerstrasse, 35042 Marburg, Germany; (K.T.); (U.G.)
| | - Jadwiga Jablonska
- Translational Oncology, Department of Otorhinolaryngology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (E.P.); (S.B.); (I.S.); (M.D.); (J.J.)
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Shovlin C, Bamford K, Sabbà C, Mager HJ, Kjeldsen A, Droege F, Buscarini E, Dupuis-Girod S. Prevention of serious infections in hereditary hemorrhagic telangiectasia: roles for prophylactic antibiotics, the pulmonary capillaries-but not vaccination. Haematologica 2019; 104:e85-e86. [PMID: 30705116 DOI: 10.3324/haematol.2018.209791] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Claire Shovlin
- Respiratory Medicine, and VASCERN HHT European Reference Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London; NHLI Vascular Science, Imperial College London, UK
| | - Kathleen Bamford
- Department of Microbiology and VASCERN HHT European Reference Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Carlo Sabbà
- Center for Rare Diseases, "Frugoni" Internal Medicine Unit, Interdepartmental HHT Center, Interdisciplinary Department of Medicine and VASCERN HHT European Reference Centre, University of Bari School of Medicine, Italy
| | - Hans-Jurgen Mager
- Department of Pulmonology and VASCERN HHT European Reference Centre, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | - Anette Kjeldsen
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Odense University Hospital, University of Southern Denmark, Denmark
| | - Freya Droege
- Department of Otorhinolaryngology and VASCERN HHT European Reference Centre, Essen University Hospital, Germany
| | - Elisabetta Buscarini
- Gastroenterology Department and VASCERN HHT European Reference Centre, Maggiore Hospital, ASST Crema, Italy
| | - Sophie Dupuis-Girod
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique, and VASCERN HHT European Reference Centre/centre de Référence pour la maladie de Rendu-Osler, France, and Université de Lyon, Faculté de médecine, France
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Andersen JH, Kjeldsen AD. Patient-recorded benefit from nasal closure in a Danish cohort of patients with hereditary haemorrhagic telangiectasia. Eur Arch Otorhinolaryngol 2019; 277:791-800. [PMID: 31845036 DOI: 10.1007/s00405-019-05758-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/05/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nasal closure, also known as the modified Young's procedure was introduced in Denmark in 2008, as a surgical solution to severe epistaxis in patients with hereditary haemorrhagic telangiectasia (HHT). The objective of this study was to report the overall satisfaction of the procedure from a patient's point of view as well as the occurrence of complications. METHODS All the HHT patients who underwent nasal closure from 2008 to 2018 were included in the study. The patients were evaluated for postoperative complications and subjective outcome using Glasgow Benefit Inventory (GBI). RESULTS Ten patients were included in the study and were observed for a mean of 64 months. None of the patients was completely free of complications, and reversal was requested in a single case. Haemoglobin levels rose with an average of 2.8 g/dl. The average GBI score after surgery was 38.05. Nine of ten patients would recommend nasal closure to fellow HHT patients. CONCLUSION Nasal closure is highly recommended among patients, but due to the rate of postoperative complications, the procedure should be reserved for a carefully selected group of HHT patients.
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Affiliation(s)
- Jonas Hjelm Andersen
- Department of ORL-Head and Neck Surgery, Odense University Hospital, 5000, Odense C, Denmark
| | - Anette Drøhse Kjeldsen
- Department of ORL-Head and Neck Surgery, Odense University Hospital, 5000, Odense C, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- HHT-WG VASCERN (European Reference Network for Vascular Disease), Paris, France.
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Al-Samkari H, Albitar HA, Olitsky SE, Clancy MS, Iyer VN. Systemic bevacizumab for high-output cardiac failure in hereditary hemorrhagic telangiectasia: an international survey of HHT centers. Orphanet J Rare Dis 2019; 14:256. [PMID: 31727111 PMCID: PMC6857247 DOI: 10.1186/s13023-019-1239-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/22/2019] [Indexed: 11/20/2022] Open
Abstract
Background Systemic bevacizumab is a novel targeted anti-angiogenic therapy for high-output cardiac failure (HOCF) in hereditary hemorrhagic telangiectasia (HHT) but published data is limited. This survey-based study measured physician-reported safety, effectiveness and current treatment practices for systemic bevacizumab in HHT-HOCF. Methods A 27-item survey was sent to center directors of 31 international HHT Centers of Excellence. Results Response rate was 74% with centers reporting 150 total patients receiving systemic bevacizumab for HHT-HOCF. Approximately two-thirds of centers had treated ≥5 patients. All centers utilize a 5 mg/kg dose for induction treatment and most administer 6 doses (range, 4–6) every 2 weeks, although maintenance regimens varied considerably. Center directors reported bevacizumab to be effective, with 55% reporting significant improvement in cardiac index and HOCF symptoms in most patients treated with bevacizumab, although normalization of cardiac parameters was uncommon. Adverse events were uncommon with three-quarters of centers reporting adverse event rates < 10%. Discontinuation for adverse events or ineffectiveness was rare. Bevacizumab was typically administered by hematologists and pulmonologists (50 and 39% of centers, respectively), with highly variable thresholds for initiation. Although half the centers reported difficulty with the insurance approval process, 70% of centers were ultimately able to obtain coverage for most or all of their patients. Conclusions Systemic bevacizumab is a widely-used therapy for HHT-HOCF with reasonable safety and effectiveness. HHT centers appear to vary considerably in maintenance treatment practices and disease severity thresholds for initiation of bevacizumab in HHT-related HOCF.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place Suite 118 Office 112, Boston, MA, 02114, USA.
| | - Hasan A Albitar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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