New Treatment Strategies in

Haemoglobinopathies

Dr Baba Inusa
Consultant and Lead,
Paediatric Haemoglobinopathy
Evelina Children’s Hospital, St Thomas Hospital

26th September, 2008

 New Management Strategies

• Summary of pathology

• Common clinical scenarios

• Therapeutic Approaches

• Hydroxyurea

• Summary
Single gene mutation….
… and sickled red cells.
 10 year old SCA
• Massive Splenemegaly,
– Repeated Transfusion, declined splenectomy

• Admitted with pain X 3 in twelve eight months

• TCD >200cm
– started prophylactic transfusion, Allo-immunisation- anti-E and
transfusion reaction

• 2 further Acute Chest Syndromes

– What options
 8 year old Female Hb SS
• Hb SS diagnosed at Birth
• Repeated VOC and ACS and increasing
length of hospital stay
• TCD-conditional, repeat normal
• Nicosan suggested to family
• Next steps
 Therapeutic approaches
• Inhibition of red cell dehydration
• Nitric oxide augmentation

• Hb F reactivation
• Anti-adhesion e.g. specific monoclonal antibodies,
HU

• Anti-sickling e.g.5- hydroxymethyl-2-furfural

GARDOS Channel
 Cellular hydration

Gardos channel blockers

• ICA17043
• Clotrimazole

KCl cotransport modulators

• Magnesium
 Mechanisms for Sickle Cell Dehydration
Blockers Deoxygenation
 Clotrimazole, ICA-17403
 Mg2+ HbS Polymerization
 Dipyridamole
Membrane Permeabilization
K+ Na +
Ca++ HCO3

[K+] [Na+]
[Ca++]

Deoxygenation
Induced pathway H+
[ K+]

H2O H2O
Cl K+

K+ Cl
Gardos Channel K-Cl Cotransport
NITRIC OXIDE
 Nitric Oxide (NO)

• Regulates blood vessel tone

• Inhibitor of vascular remodelling
• Down regulates endothelial adhesion
molecules
• Inhibits platelet aggregation
• Role in ischaemia-reperfusion injury
• Possible inhibitory role in HbS polymerisation
 NO/Arginine diagram
Nitric oxide
Arginine synthase Nitric oxide (NO)
+
citruline

Arginine Arginase Ornithine + Urea

Increasing levels of Hb F
 Foetal Haemoglobin (Hb F) interaction with
Hb S
Mechanism of switch for Hb F to Hb S
• Gene silencing is responsible for the switch from ε-chain
(embryonic Hb) to γ-chain (Hb F).
• The switch from γ to β-chain (Hb A) synthesis is probably by
competition and also the methylation of beta globin promoter.

Reversal of switch from Hb S to Hb F

• Hypomethylation methods chromatin remodelling complex
polypyrimidine in adult cells

Beneficial Action of Hb F
F dissociates to a dimer to combine with S as α2βs1 γ 1
which does not form a tetramer
 Pharmacologic modifiers

Two broad groups

• Drugs which modify DNA in order to promote γ-globin
expression
• Drugs that create an environment which promotes Hb F
cells production

• 1982 DeSimone et al showed

azacytidine in baboons led to significant
Hb F elevation
– De-represion of γ-chain synthesis, reversal of the switch
from β-chain
– Recruitment of early red cell precursors during recovery
from drug induced marrow suppression
– Direct programming of relatively late red cell precursors
 Pharmacologic Hb F modifiers

• Hydroxyurea (less toxic) – early red

cells (↑Hb F/F cells)

• Decitabine (5-aza-2‘-deoxycitidine)

• Arginine Butyrate infusion trial increased Hb F

7% to 21% (first observation in babies of diabetic
mothers)
Foetal Haemoglobin (Hb F) interaction with
Hb S

• 1948 Janet Watson observes- Red

cells of newborn with SCA do not
sickle ?inhibition due to Hb F

• Milder sickle cell features in Saudi

Arabians who were found to have
high level of Hb F in adult life
Lentivirus vector gene therapy
reversing Hb F switch
Butyrate
 Butyrates

• Short chain fatty acid

• Inhibition of histone deacetylases (HDAC)
• Increase histone acetylation
• Large volume
• Combination with HU
Decibitane
 Decitabine
• Analogue of 5 azacytidine
• DNMT inhibitor
• Hypomethylation of DNA
• SC /IV
• Low dose protocols
• HU responders & non responders
• Mild to moderate leucopenia
• Thrombocytosis
• Increase in HbF, Fcells, haemoglobin
• Decrease in reticulocyte & bilirubin
Hydroxyurea – Success in SCD?
Hydroxycarbamide
 Hydroxycarbamide – Mode of
Action
• Increases HbF levels
• Decreases wbc and plts
• Decreases adhesion of red cells to
endothelium
• Decreases adhesion molecules
• NO donor
– vasodilation
 Potential mechanisms of benefits
• HU Nitric Oxide (NO) in aqueous solutions
– NO suggested to be involved in the clinical response
– But low levels present and has very short half-life
– Therefore unlikely unless involved in pathway of
increasing HbF
• Myelo-suppressive effects on white blood cell and
platelet levels
– Rapid therapeutic effects before significant increase in HbF
– Past studies have shown correlation between high WCC
and more severe disease
• BUT these are speculative theories only
Figure 1. Mechanisms of action of hydroxyurea

Rosse, W. F. et al. Hematology 2000;2000:2-17

 Hydroxyurea effects on blood vessels

Cokic, V. P. et al. Blood 2006;108:184-191

 Hydroxyurea in SCD
MSH (Charache) 1995, New Eng. J. Med
 Double blind RCT
Treated Placebo p
 Objective: To reduce
painful crisis in those
who have > 3/yr over
preceding 12 months
Crises/yr 2.5 4.5 <0.001
299 adults
 Chest recruited25
syndrome 51 <0.001
 Trial stopped at 21
months
Transfusions 48 73 0.001
 No important adverse
effects
Possible adverse effects of HU
treatment in SCD (MSH)
18

16 HU
Placebo
14

12

10

0 s
s yr
o si ur) 2
er cr fem at
lc e
n r ain
U ic s o g
g t t )
Le p u
se er i gh (%
A m e
u W
(h
Possible adverse effects of Hb
treatment in SCD (MSH)
70

60 1-2 visits HU
1-2 visits Placebo
3+ visits HU
50 3+ visits Placebo

40
%

30

20

10

0
ss sh r ce er
o ra ve an h
irl in Fe rb Ot
Ha Sk stu
di
GI
 The future of Hydroxyurea
• MSH study still following up on patients over
long term period
• Up to 40% of patients currently not responding
as expected
• Maximum value of HU approx. 20%
• But cannot entirely disregard effect of HU in
some patients
– Transfusion status must be taken into
consideration
 Hydroxyurea in children
• Belgian Paediatric cohort
– Reduced admissions and inpatient days
– No major toxicities
• HUG/KIDS
– No major toxicity or growth failure
– No adverse effects on development
• Other studies
– Decreased acute chest crises
– Decreased transfusions

Ferster et al 1996, 2001. Wang et al 2002

 Frenette, P. S. et al. J. Clin. Invest. 2007;117:850-858

Copyright ©2007 American Society for Clinical Investigation

Table 1. Laboratory parameters and TCD flow velocities for 37 children with SCA, before hydroxyurea therapy and after reaching MTD

Before hydroxyurea, Before hydroxyurea

Hydroxyurea at MTD
P Mean ± 1 SD Median Mean ± 1 SD Median
P

Mean ± 1 SD Median Mean ± 1 SD Median

Age, y 6.8 ± 3.5 5.6 7.6 ± 3.2 6.8 NA

Hb, g/dL 7.8 ± 1.1 7.8 9.4 ± 1.0 9.4 < .001
Hematocrit, % 22.5 ± 3.3 22.0 26.8 ± 3.0 26.5 < .001
MCV, fL 86 ± 8 88 104 ± 9 103 < .001
HbF, % 10.3 ± 6.6 9.9 22.7 ± 7.9 23.3 < .001
R MCA, cm/s 166 ± 27 162 135 ± 27 134 < .001
L MCA, cm/s 168 ± 26 166 142 ± 27 144 < .001
R ACA, cm/s 130 ± 25 127 110 ± 33 98 .006
L ACA, cm/s 132 ± 29 133 113 ± 29 114 .008
R PCA, cm/s 85 ± 30 87 76 ± 23 78 NS
L PCA, cm/s 91 ± 29 90 73 ± 24 77 .006
 Long-term effect of hydroxyurea therapy on TCD flow velocities. Children with SCA and increased
baseline TCD velocities received hydroxyurea therapy at MTD. The maximum TCD velocity is shown
after reaching MTD and then in long-term follow-up for 28 children. There was a significant decrease
from baseline TCD flow velocities to the MTD values (P < .001), and this decrease was sustained at
long-term follow-up.

Zimmerman, S. A. et al. Blood 2007;110:1043-1047

Copyright ©2007 American Society of Hematology. Copyright restrictions may apply.

 Median time-averaged maximum velocity (TAMV) at the first transcranial doppler (TCD)
in patients treated and not treated with hydroxyurea for each age category. Box plots show
medians with 25 percentiles; bars represent percentiles 10-90 sd.

Lefevre, N. et al. Blood 2008;111:963-964

Copyright ©2008 American Society of Hematology. Copyright restrictions may apply.

 Effect of hydroxycarbamide on
mortality and morbidity
• Data from the follow-up of MSH
patients, 233 patients; 1992 – 2001

• Estimated overall reduction in mortality

over 9 years was 40%
– High overall mortality
– Average age 32 years
– Severe phenotype
Steinberg et al. JAMA 2003
Hydroxycarbamide and neurological
function
• Hydroxyurea lowers transcranial Doppler flow
velocities in children with SCD
– Improvement in 14/15 patients with conditional TCDs
and 5/6 patients with abnormal TCDs
• May have role in patients who refuse transfusion

• No evidence of 2o stroke prevention

– 3/16 children had recurrent stroke on changing from
transfusion to hydroxycarbamide

Zimmerman et al. Blood 2007, Ware et al Blood 1999.

Hydroxycarbamide and renal
function
Retrospective single centre study
• 3 children with significant
proteinuria
• Enalapril did not correct
proteinuria
• Addition of hydroxycarbamide was
associated with normalisation of
protein-creatinine ratio
Fitzhugh et al 2005
 Hydroxyurea
Before hydroxyurea
at MTD
P
Mean ± 1 SD Median Mean ± 1 SD Median

Age, y 6.8 ± 3.5 5.6 7.6 ± 3.2 6.8 NA

Hb, g/dL 7.8 ± 1.1 7.8 9.4 ± 1.0 9.4 < .001
Hematocrit, % 22.5 ± 3.3 22.0 26.8 ± 3.0 26.5 < .001
MCV, fL 86 ± 8 88 104 ± 9 103 < .001
HbF, % 10.3 ± 6.6 9.9 22.7 ± 7.9 23.3 < .001
R MCA, cm/s 166 ± 27 162 135 ± 27 134 < .001
L MCA, cm/s 168 ± 26 166 142 ± 27 144 < .001
R ACA, cm/s 130 ± 25 127 110 ± 33 98 .006
L ACA, cm/s 132 ± 29 133 113 ± 29 114 .008
R PCA, cm/s 85 ± 30 87 76 ± 23 78 NS
 Using hydroxycarbamide
• Unlicensed indication
• Document indication for use
• Patient information leaflet -
pregnancy
• Starting dose 15mg/kg
• Increase by 5mg/kg increments
– Depending on clinical response and
HbF
• ? Increase to Maximum Tolerated
Dose (MTD)
 Using hydroxycarbamide

• Monitor blood counts

– Weekly initially
– Increase up to 8 weekly
• Interrupt or dose reduce if:
– Hb > 3g/dl over baseline
– Retics < 1%
– Neuts < 1.5 x 109/l
– Platelets < 80 x 109/l
• Atweh GF, Schechter AN: Pharmacologic induction of fetal hemoglobin:
raising the therapeutic bar in sickle cell disease. Current Opinion in
Hematology 2001,8:123–130.

• de Montalembert M, Belloy M, Bernaudin F, Gouraud F, Capdeville R,

Mardini R, Philippe N, Jais J, Bardakdjian J, Ducrocq R, Maier-Redelsperger
M, Elion J, Labie D, Girot R: Three-Year Follow-Up of Hydroxyurea
Treatment in Severely Ill Children with Sickle Cell Disease. Journal of
Pediatric Hematology/Oncology 1997,19(4):313-318.

• Gulbis B, Haberman D, Dufour D, Christophe C, Vermylen C, Kagambega F,

Corazza F, Devalck C, Dresse MF, Hunninck K, Klein A, Le PQ, Loop M, Maes
P, Philippet P, Sariban E, Van Geet C, Ferster A: Hydroxyurea for sickle cell
disease in children and for prevention of cerebrovascular events: the
Belgian experience. The American Society of Hematology
2005,105(7):2685-2690.

• Steinberg MH, Barton F, Castro O, Pegelow CH, Ballas SK, Kutlar A, Orringer
E, Bellevue R, Olivieri N, Eckman J, Varma M, Ramirez G, Adler B, Smith W,
Carlos T, Ataga K, DeCastro L, Bigelow C, Saunthararajah Y, Telfer M,
Vichinsky E, Claster S, Shurin S, Bridges K, Waclawiw M, Bonds D, Terrin M:
Follow-Up of Hydroxyurea Treatment in Severely Ill Children with Sickle Cell
Disease. Journal of American Medical Association 2003,289(13):1645-1651.

• Coleman E and Inusa B. Sickle cell anemia: Targeting The Role of Fetal
Hemoglobin in Therapy. Clincal Pediatrics 2007; 5