How I manage medical complications of beta-thalassemia in adults

The complex pathophysiology in beta-thalassemia can translate to multiple morbidities that affect every organ system. Improved survival due to advances in management meant that patients are exposed to the harmful effects of ineffective erythropoiesis, anemia and iron overload for a longer duration, and we started seeing new or more frequent complications in adult compared with younger patients. In this article, we highlight particular aspects of managing adult patients with beta-thalassemia utilizing our own experience in treating such patients. We cover both transfusion-dependent and non-transfusion-dependent forms of the disease and tackle specific morbidities of highest interest

β-Thalassemia intermedia : morbidity uncovered

The research presented in this thesis provides several novel insights regarding the _-thalassemia intermedia phenotype. Earlier studies observed that patients with _-thalassemia intermedia experience a clinical complications profile that is different from that in patients with _-thalassemia major; which was primarily attributed to their transfusion-independence. In this work, a variety of clinical morbidities were explored and their associations with the underlying disease pathophysiology and risk factors were examined. The morbidities evaluated throughout the studies involved several organs and organ systems including the vasculature (venous thrombosis, pulmonary artery hypertension, cerebrovascular disease, and leg ulcers), heart, liver, kidney, endocrine glands (diabetes mellitus, hypothyroidism, and hypogonadism), bone (osteoporosis), and the hematopoietic system (extramedullary hematopoietic tumors). Findi ngs confirm that _-thalassemia intermedia should no longer be regarded as a mild form of thalassemia as patients experience serious manifestations involving almost every organ system.UBL - phd migration 201

Iron deficiency anaemia revisited

Iron deficiency anaemia is a global health concern affecting children, women and the elderly, whilst also being a common comorbidity in multiple medical conditions. The aetiology is variable and attributed to several risk factors decreasing iron intake and absorption or increasing demand and loss, with multiple aetiologies often coexisting in an individual patient. Although presenting symptoms may be nonspecific, there is emerging evidence on the detrimental effects of iron deficiency anaemia on clinical outcomes across several medical conditions. Increased awareness about the consequences and prevalence of iron deficiency anaemia can aid early detection and management. Diagnosis can be easily made by measurement of haemoglobin and serum ferritin levels, whilst in chronic inflammatory conditions, diagnosis may be more challenging and necessitates consideration of higher serum ferritin thresholds and evaluation of transferrin saturation. Oral and intravenous formulations of iron supplementation are available, and several patient and disease-related factors need to be considered before management decisions are made. This review provides recent updates and guidance on the diagnosis and management of iron deficiency anaemia in multiple clinical settings

An update on thalassemia intermedia

Thalassemia intermedia is a genetically diverse group of diseases that is the result of an imbalance in the production of the alpha and beta chains with ensuing chronic hemolysis, ineffective erythropoiesis, and iron overload. Resulting complications include bone changes, hypercoagulability, and end-organ damage due to iron overload. This decade has witnessed major breakthroughs in the management of thalassemia. In this article, we examine these novelties in therapy including iron chelation therapy, stem cell transplant, and gene therapy. Iron chelation therapy has been revolutionized with the advent of deferasirox, a once-daily oral iron chelator, that has been shown to be safe and efficacious. Gene therapy was also at the core of this revolution with the discovery of novel gene elements and viral vectors allowing for better control and improved outcomes.La thalass\ue9mie interm\ue9diaire englobe un groupe de maladies diverses r\ue9sultant d\u2019un d\ue9s\ue9quilibre entre la production des cha\ueenes alfa et b\ueata qui aboutit \ue0 une h\ue9molyse chronique, une \ue9rythropo\uef\ue8se inefficace et une surcharge en fer. Les complications engendr\ue9es par cette maladie sont un changement dans la constitution des os, un \ue9tat d\u2019hypercoagulabilit\ue9, et des organes majeurs endommag\ue9s suite au surplus de fer. La derni\ue8re d\ue9cennie a vu d\u2019importantes avanc\ue9es dans le traitment de la thalass\ue9mie. Sont examin\ue9es ici les toutes derni\ue8res th\ue9rapeutiques : la ch\ue9lation du fer, la greffe de cellules souches et la th\ue9rapie g\ue9n\ue9tique. L\u2019introduction de deferasirox, un ch\ue9lateur du fer administr\ue9 une fois par jour par voie orale, a r\ue9volutionn\ue9 la ch\ue9lation du fer et s\u2019est impos\ue9 comme \ue9tant un m\ue9dicament s\ufbr et efficace. La th\ue9rapie g\ue9n\ue9tique a aussi \ue9t\ue9 une innovation charni\ue8re dans les nouveaux traitements, surtout avec la d\ue9couverte r\ue9cente d\u2019\ue9l\ue9-ments g\ue9n\ue9tiques et vecteurs viraux qui permettent un meilleur contr\uf4le et am\ue9liorent les r\ue9sultats

β-Thalassemia : new therapeutic modalities, genetics, complications, and quality of life

Retinoic acid (RA) is a positive regulator of P19 cell differentiation. Silencing of pre-B cell leukemia transcription factors (PBXs) expression in P19 cells (AS cells) results in a failure of these cells to differentiate to endodermal cells upon RA treatment. Chicken Ovalbumin Upstream Promoter Transcription Factor I (COUP-TFI) is an orphan member of the steroid-thyroid hormone superfamily. RA treatment of wild type P19 cells results in a dramatic increase in the expression of COUP-TFI; however, COUP-TFI mRNA levels fail to be elevated upon RA treatment of AS cells indicating that PBX expression is required for elevation in COUP-TFI expression. To study the role of COUP-TFI during RA-dependent differentiation of P19 cells, AS cells that inducibly express various levels of COUP-TFI were prepared. Exogenous expression of COUP-TFI in AS cells, in a dose-dependent fashion, leads to growth inhibition, modest cell cycle disruption, and early apoptosis. Furthermore, AS cells can overcome the blockage in RA-dependent differentiation to endodermal cells when either pharmacological levels of COUP-TFI are expressed or a combination of both the expression of physiological levels of COUP-TFI and RA treatment. Additionally, the mRNA level of several pluripotency associated genes including OCT-4, DAX-1, and SF-1 in the COUP-TFI expressing AS cells are reduced. Moreover, analysis of the expression of primary RA response genes indicates that COUP-TFI is involved in the regulatory modulation of the expression of at least two genes, CYP26A1 and HoxA1. These studies demonstrate that COUP-TFI functions as a physiologically relevant regulator during RA-mediated endodermal differentiation of P19 cells

A paradigm shift on beta-thalassaemia treatment : how will we manage this old disease with new therapies?

Beta-thalassaemia causes defective haemoglobin synthesis leading to ineffective erythropoiesis, chronic haemolytic anaemia, and subsequent clinical complications. Blood transfusion and iron chelation allow long-term disease control, and haematopoietic stem cell transplantation offers a potential cure for some patients. Nonetheless, there are still many challenges in the management of beta-thalassaemia. The main treatment option for most patients is supportive care; furthermore, the long-term efficacy and safety of current therapeutic strategies are limited and adherence is suboptimal. An increasing understanding of the underlying molecular and cellular disease mechanisms plus an awareness of limitations of current management strategies are driving research into novel therapeutic options. Here we provide an overview of the current pathophysiology, clinical manifestations, and global burden of beta-thalassaemia. We reflect on what has been achieved to date, describe the challenges associated with currently available therapy, and discuss how these issues might be addressed by novel therapeutic approaches in development

Fetal hemoglobin levels and morbidity in untransfused patients with β-thalassemia intermedia

To evaluate the association between fetal hemoglobin (HbF) levels and morbidity in \u3b2-thalassemia intermedia (TI), we analyzed data from 63 untransfused patients who had also never received HbF induction therapy. Patient records were reviewed for any history of 10 predefined morbidities. Laboratory measurements for markers of ineffective erythropoiesis were also obtained. The mean age of patients was 32.1 years, 47.6% were males, and the median HbF level was 37.2%. HbF levels correlated positively with total hemoglobin, yet negatively with growth differentiation factor-15 and non-transferrin-bound iron levels. Median HbF levels were significantly lower in patients with the majority of evaluated morbidities than in those without. There was a strong negative adjusted linear correlation between the HbF level and the total number of morbidities (R(2) = 0.825, P < .001). The HbF threshold of 63.7% had 95.5% sensitivity and 100% specificity for ensuring absence of morbidity. There exists a strong association between HbF levels and morbidity in the subset of untransfused patients with T

Iron deficiency in chronic heart failure: case-based practical guidance

In patients with chronic heart failure, iron deficiency, even in the absence of anaemia, can aggravate the underlying disease and have a negative impact on clinical outcomes and quality of life. The 2016 European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure recognize iron deficiency as a co-morbidity in chronic heart failure and recommend iron status screening in all newly diagnosed patients with chronic heart failure. Furthermore, the guidelines specifically recommend considerations of intravenous iron therapy, ferric carboxymaltose, for the treatment of iron deficiency. However, in spite of these recommendations, iron deficiency remains often overlooked and undertreated. This may be due, in part, to the lack of clinical context and practical guidance accompanying the guidelines for the treating physician. Here, we provide practical guidance complemented by a case study to assist and improve the timely diagnosis, treatment, and routine management of iron deficiency in patients with chronic heart failure

Sotatercept, a novel transforming growth factor beta ligand trap, improves anemia in beta-thalassemia: a phase 2, open-label, dose-finding study

\u3b2-thalassemia, a hereditary blood disorder caused by defective synthesis of hemoglobin \u3b2 globin chains, leads to ineffective erythropoiesis and chronic anemia that may require blood transfusions. Sotatercept (ACE-011) acts as a ligand trap to inhibit negative regulators of late-stage erythropoiesis in the transforming growth factor beta superfamily, correcting ineffective erythropoiesis. In this phase II, open-label, dose-finding study, 16 patients with transfusion-dependent \u3b2-thalassemia and 30 patients with non-transfusion-dependent \u3b2 thalassemia were enrolled at 7 centers in 4 countries from November 2012 to November 2014. Patients were treated with sotatercept at 0.1, 0.3, 0.5, 0.75, or 1.0 mg/kg to determine a safe and effective dose. Doses were administered by subcutaneous injection every 3 weeks. Patients were treated for 6422 months. Response was assessed as a 6520% reduction in transfusion burden sustained for 24 weeks in transfusion-dependent \u3b2-thalassemia patients, and an increase in hemoglobin level of 651.0 g/dL sustained for 12 weeks in non-transfusion-dependent \u3b2-thalassemia patients. Sotatercept was well tolerated. After a median treatment duration of 14.4 months (range 0.6-35.9), no severe life-threatening adverse events were observed; 13% of patients reported serious but manageable adverse events. The active dose of sotatercept was 650.3 mg/kg for non-transfusion-dependent \u3b2-thalassemia and 650.5 mg/kg for transfusion-dependent \u3b2-thalassemia patients. Of 30 non-transfusion-dependent \u3b2-thalassemia patients treated with 650.1 mg/kg sotatercept, 18 (60%) achieved a mean hemoglobin increase 651.0 g/dL, and 11 (37%) an increase 651.5 g/dL, sustained for 6512 weeks. Four (100%) transfusion-dependent \u3b2-thalassemia patients treated with 1.0 mg/kg sotatercept achieved a transfusion-burden reduction of 6520%. Sotatercept was effective and well tolerated in patients with \u3b2-thalassemia. Most non-transfusion-dependent \u3b2-thalassemia patients treated with higher doses achieved sustained increases in hemoglobin level. Transfusion-dependent \u3b2-thalassemia patients treated with higher doses of sotatercept achieved notable reductions in transfusion requirement. The registration number at ClinicalTrials.gov was NCT01571635