A: Deferasirox, deferiprone and desferrioxamine treatment in thalassemia major patients: cardiac iron and function comparison determined by quantitative magnetic resonance imaging. Haematologica 2011; 96

Background Oral deferiprone was suggested to be more effective than subcutaneous desferrioxamine for removing heart iron. Oral once-daily chelator deferasirox has recently been made commercially available but its long-term efficacy on cardiac iron and function has not yet been established. Our study aimed to compare the effectiveness of deferasirox, deferiprone and desferrioxamine on myocardial and liver iron concentrations and bi-ventricular function in thalassemia major patients by means of quantitative magnetic resonance imaging. Design and Methods From the first 550 thalassemia subjects enrolled in the Myocardial Iron Overload in Thalassemia network, we retrospectively selected thalassemia major patients who had been receiving one chelator alone for longer than one year. We identified three groups of patients: 24 treated with deferasirox, 42 treated with deferiprone and 89 treated with desferrioxamine. Myocardial iron concentrations were measured by T2* multislice multiecho technique. Biventricular function parameters were quantitatively evaluated by cine images. Liver iron concentrations were measured by T2* multiecho technique. Results The global heart T2* value was significantly higher in the deferiprone (34±11ms) than in the deferasirox (21±12 ms) and the desferrioxamine groups (27±11 ms) (P=0.0001). We found higher left ventricular ejection fractions in the deferiprone and the desferrioxamine versus the deferasirox group (P=0.010). Liver iron concentration, measured as T2* signal, was significantly lower in the desferrioxamine versus the deferiprone and the deferasirox group (P=0.004). Conclusions The cohort of patients treated with oral deferiprone showed less myocardial iron burden and better global systolic ventricular function compared to the patients treated with oral deferasirox or subcutaneous desferrioxamine. Key words: thalassemia, iron chelation therapy, cardiac magnetic resonance imaging. Citation: Pepe A, Meloni A, Capra M, Cianciulli P, Prossomariti L, Malaventura C, Putti MC, Lippi A, Romeo MA, Bisconte MG, Filosa A, Caruso V, Quarta A, Pitrolo L, Missere M, Midiri M, Rossi G, Positano V, Lombardi M, and Maggio A. Deferasirox, deferipron

Deferasirox, deferiprone and desferrioxamine treatment in thalassemia major patients: cardiac iron and function comparison determined by quantitative magnetic resonance imaging

Background Oral deferiprone was suggested to be more effective than subcutaneous desferrioxamine for removing heart iron. Oral once-daily chelator deferasirox has recently been made commercially available but its long-term efficacy on cardiac iron and function has not yet been established. Our study aimed to compare the effectiveness of deferasirox, deferiprone and desferrioxamine on myocardial and liver iron concentrations and bi-ventricular function in thalassemia major patients by means of quantitative magnetic resonance imaging. Design and Methods From the first 550 thalassemia subjects enrolled in the Myocardial Iron Overload in Thalassemia network, we retrospectively selected thalassemia major patients who had been receiving one chelator alone for longer than one year. We identified three groups of patients: 24 treated with deferasirox, 42 treated with deferiprone and 89 treated with desferrioxamine. Myocardial iron concentrations were measured by T2* multislice multiecho technique. Biventricular function parameters were quantitatively evaluated by cine images. Liver iron concentrations were measured by T2* multiecho technique. Results The global heart T2* value was significantly higher in the deferiprone (34?11ms) than in the deferasirox (21?12 ms) and the desferrioxamine groups (27?11 ms) (P=0.0001). We found higher left ventricular ejection fractions in the deferiprone and the desferrioxamine versus the deferasirox group (P=0.010). Liver iron concentration, measured as T2* signal, was significantly lower in the desferrioxamine versus the deferiprone and the deferasirox group (P=0.004). Conclusions The cohort of patients treated with oral deferiprone showed less myocardial iron burden and better global systolic ventricular function compared to the patients treated with oral deferasirox or subcutaneous desferrioxamine

Review and recommendations on management of adult female thalassemia patients with hypogonadism based on literature review and experience of ICET-A network specialists

CITATION: De Sanctis, V., et al. 2017. Review and recommendations on management of adult female thalassemia patients with hypogonadism based on literature review and experience of ICET-A network specialists. Mediterranean Journal of Hematology and Infectious Diseases, 9(1):e2017001, doi:10.4084/mjhid.2017.001.The original publication is available at https://www.mjhid.orgBackground: Multi-transfused thalassemia major (TM) patients frequently develop severe endocrine complications, mainly due to iron overload, anemia and chronic liver disease, which require prompt diagnosis, treatment and follow-up by specialists. The most common endocrine complication documented is hypogonadotropic hypogonadism which increases with age and associated comorbidities. It is thus important for physicians to have a clear understanding of the pathophysiology and management of this disorder. Also to be aware of the side effects, contraindications and monitoring of sex steroid therapy. In this paper practical ICET-A recommendations for the management of hypogonadism in adult females with TM are addressed. Methods: In March 2015, the Coordinator of the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) conducted a two-step survey to assess the attitudes and practices of doctors in the ICET-A network taking care of adult female TM patients with hypogonadism. They were clinically characterized by the absence of pubertal development, or discontinuation or regression of the maturation of secondary sex characteristics, and biochemically by persistent low FSH, LH and estradiol levels. Recently a supplementary survey on adult female hypogonadism in TM was undertaken within the ICET-A network. Results: The completed questionnaires were returned by 16 of 27 specialists (59.2%) following 590 female TM patients over the age of 18 years; 315 patients (53.3%) had hypogonadism and only 245 (74.6%) were on hormone replacement therapy (HRT). Contraceptive oral pills (COC) were the first treatment choice in 11 centres (68.7%). A wide range of COCs were used with different progestin contents. In general, the patients’ compliance to treatment was reported as good in 81.2 % of centres. The frequency of required tests for follow-up HRT, in addition to the regular check-up for thalassemia, was variable in the participating centres. Conclusions: Doctors taking care of TM patients should have sound knowledge of the pathophysiology of hypogonadism in adult females with TM. They should know the potential effects of HRT including advantages and disadvantages of estrogen and progestins. Moreover, they should keep in consideration the emotional needs of these patients dreaming to attain a full pubertal development.https://www.mjhid.org/index.php/mjhid/article/view/2017.001Publisher's versio

α-Thalassemia Associated with Hb Instability: A Tale of Two Features. The Case of Hb Rogliano or α1 Cod 108(G15)Thr→Asn and Hb Policoro or α2 Cod 124(H7)Ser→Pro.

<div><p>We identified two new variants in the third exon of the α-globin gene in families from southern Italy: the Hb Rogliano, α1 cod108 ACC>AAC or α1[α108(G15)Thr→Asn] and the Hb Policoro, α2 cod124 TCC>CCC or α2[α124(H7)Ser→Pro]. The carriers showed mild α-thalassemia phenotype and abnormal hemoglobin stability features. These mutations occurred in the G and H helices of the α-globin both involved in the specific recognition of AHSP and β1 chain. Molecular characterization of mRNA, globin chain analyses and molecular modelling studies were carried out to highlight the mechanisms causing the α-thalassemia phenotype. The results demonstrated that the α-thalassemia defect associated with the two Hb variants originated by different defects. Hb Rogliano showed an intrinsic instability of the tetramer due to anomalous intra- and inter-chain interactions suggesting that the variant chain is normally synthesized and complexed with AHSP but rapidly degraded because it is unable to form the α1β1 dimers. On the contrary in the case of Hb Policoro two different molecular mechanisms were shown: the reduction of the variant mRNA level by an unclear mechanism and the protein instability due to impairment of AHSP interaction. These data highlighted that multiple approaches, including mRNA quantification, are needed to properly identify the mechanisms leading to the α-thalassemia defect. Elucidation of the specific mechanism leads to the definition of a given phenotype providing important guidance for the diagnosis of unstable variants.</p></div

Location of residues discussed in the manuscript on the overall structure of the complex between the α-chain and AHSP and on the structure of the αβ dimer.

<p><b>A:</b> Cartoon representation of the three-dimensional structure of the complex between the α-chain and AHSP (PDB code 1Y01) [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0115738#pone.0115738.ref003" target="_blank">3</a>]. The α-chain of HbA is highlighted in cyan, whereas the AHSP molecule is in green. In this structure the position of residues 1, 74, 81–91 and 140–142 in the α-globin chain of HbA has not been determined. For this reason the structural representation lacks these residues. <b>B:</b> Cartoon representation of the three-dimensional structure of the αβ dimer from the structure of the tetrameric human deoxy hemoglobin (PDB code 2HHB) [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0115738#pone.0115738.ref023" target="_blank">23</a>]. α- and β-chains are highlighted in cyan and yellow, respectively.</p

Total ion current (TIC) of the LC-MS analysis and electrospray mass spectra of variant and normal α-chains.

<p>Liquid chromatography-mass spectrometry analysis (LC/MS) of globin chains precipitated from the hemolysate of a Hb Policoro carrier after a 20 minutes of 17% isopropanol incubation. The anomalous globin chain eluting before the normal β-globin is marked as α^V.</p

Liquid chromatography-mass spectrometry analysis (LC/MS) of the hemolysate from a Hb Rogliano carrier.

<p><b>A</b>: Total ion current (TIC) of the LC-MS analysis of the globin chains. The anomalous globin chain eluting before the normal α-globin is marked as α^V. The arrows indicated the electrospray mass spectra of the variant and the normal α-globin chains. <b>B</b> and <b>C:</b> Reverse-phase HPLC separation of globin chains. <b>B</b>: normal control; <b>C</b>: Hb Rogliano carrier. The variant α-globin chain (α^V) is indicated by an arrow.</p

Molecular characterization of the Hb Policoro.

<p><b>A:</b> DGGE of the fragment III of the α-globin genes containing the codon 124. Lanes 1 and 2: normal subjects, Lane 3: Hb Policoro heterozygote. <b>B:</b> DNA sequence of the α2-globin gene of the proband from codon 122 to codon 126; the arrow indicates the mutation. <b>C:</b> ARMS for the screening of carriers for Hb Policoro: the control amplicon was of 714 bp, the amplicon specific for the mutation was 255 bp long. Lanes 1, 2, 4: Hb Policoro heterozygotes; Lane 3: normal subject; lane 5: negative control. <b>D:</b> ARMS with the normal primer at codon 124 for the genotyping of the Hb Policoro carriers: the control amplicon was of 714 bp, the amplicon specific for the cod 124 normal allele was 139 bp long. Lanes 1, 2: Hb Policoro heterozygotes; Lane 3: compound heterozygote for the Hb Policoro and the -α^3.7 deletion; Lane 4:-α^3.7 deletion heterozygote; Lane 5: normal subject; Lane 6: negative control. The ARMS-PCR conditions were: hot start 95° for 10'; PCR: 94° for 45'', 63° for 45'', 72° for 45'', for 30 cycles.</p