Beta-ThalassemiaIntermedia:

Complications and Perspectives for Management

Farzana Sayani
Hematology Rounds
May 27, 2010
 Objectives
• To review the complications of
Thalassemiaintermedia
• To discuss treatment options for patients with
thalassemiaintermedia
 Case
• 42 yo immigrated from Albania
• Diagnosis of thalassemia made in early childhood
• No prior transfusions, No splenectomy
• Hemoglobin 70s, asymptomatic
• Cholecystectomy
• Minor fall: fracture L wrist, L pubic ramus
• Fully functional, office job, 1 son
• O/E: splenomegaly 2 cm below umbilicus, liver
span 16 cm
 Case
• Hgb 76, MCV 75, RDW 35.3
• WBC 4.7, platelets 156
• Hemoglobinopathy study:
– HbA 31.4%
– HbA2 3.4%
– HbF 59%
• Compound heterozygous
– IVS-T-110 G-A / poly-A AATAAA to AATGAA
– β+/β+
 Thalassemia

• A globin gene disorder

• Decreased rate of synthesis of one or more
globin chains
• Decreased rate of synthesis of hemoglobin
• Resultant unbalanced chain synthesis
– Excess of normal globin chainn: damage to
erythroid precursors and ineffective
erythropoeiesis
– Damage to mature erythroctyes and hemolytic
anemia
 β Thalassemia

α β Normal red blood cells

β Thalassemia
• Decreased β production
• Relatively high α

α β α precipitates
• Abnormal red blood cells
• Increased destruction
 α α/β(γ) Ratio in β Thalassemia
Decrease in β chain
production

β(γ)
Excess a chains
Fessas bodies
Mechanisms
- DNA transcriptional mutation at promotor site: usually b+
- mRNA modification at splicing or cleavage steps
- RNA mutations causing abnormal translation
- polyadenylation defects leading to unstable globins
• Complete absence of β-globin chains: β0
• Decreased production of β globin chains: β+
• > 200 mutations: most are nucleotide substitutions
 β thalassemia
Definition Genotype Hb electro. Hematology Clinical
presentation
β thal trait β/β+ or β/β0 High A2 3.5- Low MCV Normal
7% Hypochromia
HbF < 5% Mild anemia
or none
β thal β0/β0 HbF 70-95%, Low MCV HSM
intermedia β0/β+ HbA2 2% Hypochromia Intermittant
β+/β+ Trace Hb A High nRBC transfusions
β mutation + Target cells
Hb variant
β thal major β0/β0 or β0/β+ HbF 30-98% Microcytosis Transfusion
or β+/β+ or HbA2 2% Hypochromia dependent
β mutation + No Hb A High nRBC
Hb variant Target cells
Thalassemia Belt
Annual Births of Severe Thalassemia
1994 WHO
Area Pop Births Thal births
(x106) (x106) (x103)

Americas 73017.5 5
SE Asia 3150 84 120
Medit/Euro 780 11 1.6
Western 30 0.5 0.2
Pacific
Total 4690 113 126.8
Total 260
(est 2002)
ThalassemiaIntermedia: Definition
• ‘Too severe to be called minor, too mild to be
called major’
• A phenotype of intermediate clinical and
hematological severity
Differentiating TM vs TI at presentation
Parameter TM more likely TI more likely
Clinical
Presentation (years) <2 >2
Liver/spleen Severe Moderate to severe
enlargement

Hematological
Hb level 60-70 70-100
HbF (%) 50 10-50 (maybe up to 100)
HbA2 (%) < 3.5 > 3.5

Genetic
Parents Both carriers of high One or both atypical
HbA2 – βthalassemia carriers
-High HbFβthalassemia
-Borderline HbA2
• The natural history of the disease allows for
the emergence of several complications that
are relatively unique to TI compared to TM.
• Clinical presentation and sequelae span a
wide spectrum of severity.
• Optimal course of management for TI has
been hard to identify.
 Molecular basis
• Imbalance in globin chain production
• Abnormal βglobin gene function leading to
partial suppression of βglobin protein
production
• Intermediate balance of α and βglobin chains
 Clinical manifestation determined by:
Nature of specific β
thalassemia mutation
– Homozygosity for mild β+
mutation
– Compound heterozygoisity
for 2 mild mutations or mild
and severe
– Only a single βglobin locus is
affected (less common)
Coinheritance of other
genetic determinants that
modulate the imbalance
– Coinheritance of α-
thalassemia
– Coinheritance of mutations
increasing γ chain synthesis
• HPFH
• γ gene promoter
mutation
• δβthalassemia
– Heterozygous βthalassemia
with triplicatedα genes
(ααα) (rare)
• Other causes of TI
– Hb E/βthalassemia
• Worldwide most common form TI
– Hemoglobin H-constant spring
 TI: Variable phenotype
• Mild Cases
– Hgb 70-100
– Mild-moderate splenomegaly
– Generally asymptomatic until later in life
– Generally do well without transfusions
• Moderate Cases
– Hgb 60-90
– Moderate to severe splenomegaly
– Present between 1-6 years
– Able to survive without transfusions until adulthood
but have more complications
 Pathophysiology
• 3 main factors responsible for clinical
manifestations
– Ineffective erythropoiesis
– Chronic hemolytic anemia
– Iron overload
TI: Advancing age associated with
worsening anemia and ferritin

Taher et al. BJH 2010

 Complications
• Largest overview on TI from 6 comprehensive centres. N=584
• OPTIMAL CARE STUDY
• Osteoporosis 23%
• EMH 21%
• Hypogonadism 17%
• Cholelithiasis 17%
• Thrombosis 14%
• PHTN 11%
• Leg ulcers 8%
• Hypothyroidism 6%
• Heart failure 4%
• Diabetes mellitus 1.7%
Taher et al. Blood 2010
 TI: Advancing age associated with more
complications in treatment naïve patients

Taher et al. BJH 2010

 Ineffective Erythropoiesis
• Alpha chains highly unstable
• Precipitate within erythroid precursors in BM
• Membrane damage and cell death
• Is the main cause of chronic anemia
– Secondary causes of anemia
• Hemolysis of mature RBC
• Overall reduction in Hb synthesis
 ExtramedullaryHematopoiesis (EMH)
• Hypertrophy of erythroid marrow in medullary and
extramedullary sites
• Compensatory mechanism to overcome chronic
anemia
• ~60% of TI patients have EMH
– Spleen, liver
– Para spinal – spinal cord compression
– Thoracic
– Pelvic
• Treatment
– Transfusions
– Radiation
– Hydroxyurea
 Hypercoagulable State
• 8860 patients (2190 TI) assessed for thrombotic events
• Thrombotic events are 4.4 X more frequent in TI than TM
• Thrombotic events in 4% of TI patients (other studies 9.6 – 29%)
– DVT 40%
– PE 12%
– stroke 9%
• TI – more venous events
• TM – more arterial events
• Main risk factors for developing thrombosis:
– Splenectomy
– Severe anemia Hgb<90
– Age > 20
– Family history
– Previous thrombotic event

Taher et al. 2006

 Platelets

Nitric
RBCs
oxide

Hypercoagulability

Peripheral
Splenectomy blood
elements

Thrombo-
philia
 Hypercoagulable state
• Platelets
– Increased platelet activation and aggregation
• Increased urinary metabolites of prostacyclin and thromboxane A2
• Red Blood Cells
– Thalassemic RBC express negatively charged phospholipids which
increase thrombin generation. Higher in splenectomized patients.
– Increased rbc aggregation. Reduced after transfusions
• Peripheral blood elements
– Increased endothelial adhesion proteins due to endothelial injury or
activation
– RBC microparticles elevated in TI vs control. May aggravate thrombotic
events.
• Coagulation factors and inhibitors
– Decreased protein C and S
• Splenectomy
– Increased susceptibility to thrombosis
– Higher platelet counts and aggregation, increased abnormal RBC, higher
thrombin generation
 Hypercoagulable state
• Thrombotic events are more prevalent in
splenectomized TI patients who are not
transfused regularly.
• Treatments
– No or poor quality data on anticoagulants and
anti-platelet agents.
– Transfusions
• Reassess role of splenectomy
Thalassemia and heart disease

Thalassemia ThalassemiaInte
Major rmedia

Chronic Occasional
transfusions Transfusions

Chronic hypoxia
Iron overload Pulmonary
LV dysfunction hypertension
LV dysfunction
 Chronic hemolytic anemia
HbF
EMH and shunt development
High
output
Low nitric oxide state Platelet aggn
Vasoconstriction Abnormal rbc
Diffuse elastic injury Protein C, S

Vascular Hypercoagula
involvement bility
Contributors
to cardiac
complications

Iron Valvular
IE Thick, calcifications
GI absorption
overload involvement
Regurgitations
Blood transfusions Aortic stenosis
 Pulmonary Hypertension
• Leading cause of CHF in TI due to right heart
failure
• Combined effects of:
– High cardiac output
– Increased vascular tone
– Hypercoagulable state
– Increased cardiac iron
– splenectomy
 Pulmonary Hypertension
• Common in TI - 23-59%
• Measured by estimated systolic pulmonary
artery pressure on echo
– Systolic RV/RA (tricuspid) pressure gradient
– Derived from doppler tracing of tricuspid
regurgitation jet velocity (TJV)
• PHTN if:
– Increased systolic PA pressure >30mmHg or
– TJV > 2.5msec
 Pulmonary Hypertension
• Aessopos 2005: systolic PA pressures
– TI < 25 years mean 27mmHg
– TI > 25 years mean 34.3 mmHg
– TM > 25 years mean 23 mmHg
• Cause of significant morbidity and mortality
• Need better understanding and improved
targeted therapy
 Pulmonary Hypertension
• Annual echo in adults
• Cardiac catheterization for significant PHTN >
35 mmHg
• Role of anticoagulation?
• Considerations for transfusions
– Reduced hemolysis induced damage via NO
– Improved tissue oxygenation
– Decreased procoagulant effect of RBC
• Sildenafil, prostacyclin analogues
 Iron Overload in TI
• Differences in iron loading between TM and TI
• TM: iron overload primarily via transfusions
• TI: iron overload via increased intestinal
absorption
• Serum ferritin underestimates the true iron
load in TI patients. Ferritin is significantly
lower than in those with TM despite
comparable levels of liver iron.
Iron storage and distribution
 Iron accumulation

Hepcidin in normal state Hepcidin in iron loading

anemiaseg. TI
Regulators of Hepcidin: GDF15
Growth and Differentiation Factor
GDF15

Increased in TI > TM > SCD

Tanno et al. Nature Medicine 2007

Sayani et al. ASH Meeting 2008
Regulators of hepcidin: HIF

Peyssonnaux 2007 JCI

Iron regulation in TI
 Iron regulation in TI with transfusions

Transfusions: lead to increased hepcidin production, decreased

GI iron absorption, increased uptake of iron into the RE system,
and increased ferritin.
Management of iron overload in TI
• No clear guidelines for TI
• TI patients need direct assessment of body
iron levels to guide therapy.
• Need iron chelation once transfusions start.
Taher et al. BJH. 2009
 Bone Disease in Thalassemia
• >50% of patients with TI and TM have low bone mass
• 20% adults have vertebral compression fractures
• Osteoporosis: BMD T score -2.5 SD or greater below mean

• Risk factors
– Bone marrow activity
– Iron overload
– Activity
– Genetic modifiers
– Ethnicity
– diet
 Acquired factors contributing to reduced
BMD in thalassemia
• Bone marrow expansion
– Mechanical interruption of bone formation
• Endocrine complications
– Hypogonadism
– Hypothyroidism
– Hypoparathyroidism
• Iron overload
– Iron deposits into crystals of calcium hydroxyapatite, Impaired
osteoid maturation and inhibits mineralization, focal
osteomalacia
• Vitamin and trace mineral deficiences
– Vitamin C, D, Zinc
• Physical activity
 Genetic factors that predispose to
reduced BMD
• Genetic factors play an important role in
development of low bone mass and
osteoporotic fractures.
• Genetic variants known to be involved in
pathogenesis of thalassemia induced
osteoporosis:
– COLIA1 – collage type Ia1 gene
– VDR – Vitamin D receptor
– TGF-b
 Bone disease
• Significant cause of morbidity
• Frequent lack of early diagnosis
• Clinical presentation
– Growth failure
– Spinal deformities
– Limp
– Fractures
– Pain
– Arthritis
– Nerve compression
 Bone Disease
• Fractures
• 12.% in TI
• 7.4% in E/beta thal
• 16.6% in TM
• Increased prevalence with age (23% > 20yrs)
• More in patients with low BMD (-2.8 score)

Vogiatzi et al. Bone. 2005

 Bone disease: Therapy
• Prevention
– BMD assessment yearly starting in adolescence
– Exercise
– Iron chelation
– Transfusions to suppress EMH
• Calcium > 1500 mg/ day
• Vitamin D
• Estrogen replacement
• Bisphosphonates: inhibit resorption
• Alendronate, pamidronate, zoledronic acid: greatest efficacy
• Zoledronic acid: promising results
– Improved BMD, reduced pain x 1 year
– Improved BMD, decrease ALP x 2 years
– Improved BMD and bone turnover makers

(Otrok 2006, Gilfillan 2006, Voskaridou 2006)

 Pregnancy and Infertility
• Delayed puberty
• Majority have normal sexual development
• Spontaneous pregnancy
• Increased spontaneous abortions, pre-term
labor, IUGR, due to anemia
• Some require transfusions during pregnancy
– Supplemental folic acid during pregnancy
– Maintain Hb 90-100
 Pyschosocial Burden
• Adjustment issues, anxiety, depression
• No less severe than issues in TM
• Low excersie capacity
• Severe QoL issues
 Other complications
• Leg ulcers
– Reduced tissue oxygenation, thin fragile skin
– Low Zinc
– Local treatment, transfusions, zinc
• Hepatitis B, C
• Gallstones
– Very common
– 70-85% cholecystectomy
– Presence of Gilbert’s syndrome increases stone
formation in thalassemia.
 Who to Transfuse?
• Symptoms at young age
• Growth failure
• Steady Hgb 60-70
• Marrow expansion
• Severe DNA mutations
• Failed drug treatment
• Hypersplenism
• Failed prior splenectomy
• Adults: QoL, psychosocial well being
• Subjective findings
– Anorexia, weight loss
– Sleep problems, lethargy, irritability
 OPTIMAL CARE STUDY
• Study profile:
– Regular transfusions 52%
– Occasional transfusions 25%
• Transfusion protective for
– Thrombosis
– EMH
– PHTN
– Heart failure
– Cholelithiasis
– Leg ulcers
• Transfusions associated with increased endocrinopathy
 Splenectomy and TI
• Controversial
• Successful in 50-60%
• Alternative to transfusion
• Now uncommon
• Indications
– Decrease in Hb
– Hypersplenism
– Symptomatic splenomegaly
– Poor growth, health, unable to get blood
 Splenectomy and TI
• Risk of complications
– Infections, thrombophilia, PHTN
• Need anti-platelet agent post
• Vaccinations
• Immediate attention to fever

• OPTIMAL CARE STUDY

– Splenectomy and older age associated with increased
risk of most disease-related complications
 Fetal Hemoglobin Augmentation
• Hydroxyurea
• Butyrate
• Erythropoietin
• Decitabine
 Goals of Therapy in TI
• Increase γ to bind excess
α

• Ameliorate the imbalance

in globin chain synthesis
• Decrease ineffective
α β α β erythropoiesis
• Reduce anemia
γ γ • Genetic evidence that
δ δ
higher HbF levels have
milder disease
Normal b-thalassemia
 Hydroxyurea
• Induce proliferation of erythroid precursors,
reactivation of γ genes
• Ameliorate the imbalance in globin chain synthesis
• Few studies. Small N. Response rate 30-90%
• Largest report of 163 TI patients
• 91% responded
• Increase in Hgb (mean 95)
• Improved exercise tolerance, sense of well being
• No change in spleen size
• 10 yr follow up: well tolerated, no malignancies

Karimi et al. 2005

 Hydroxyurea
• OPTIMAL CARE STUDY
• Patients on HU: 35%
• Hydroxyurea protective for
– EMH
– PHTN
– Leg ulcers
– Hypothyroidism
– Osteoporosis
• Hydroxyurea associated with hypogonadism
Taher et al. Blood. 2010
 Butyrate
• Specific activation of γglobin gene
• Variable responses
• May have other effects on other globin genes
eg. alpha.
 Decitabine
• DNA hypomethylation – prevention of silencing of
gamma globin gene
• Does not impair protein synthesis therefore less
carcinogenic potential
• No carcinogenic risk in animal studies or secondary
malignancy in humans (>10yr tx)
• Multiple studies in SCD
– Small N
– Increase HbF by 10%
– Rise in Hgb 10 points
• Need large studies, ? Role in thalassemia, ? Side effects
 Summary
• TI poses different challenges compared to TM
• Variable genotypic and phenotypic expression makes
for a variable clinical presentation.
• No overall consensus on treatment guidelines
• Major complications due to ineffective erythropoeisis,
chronic anemia and iron overload
• Major complications more common in TI than TM
include hypercoagulability and PHTN especially in
patients with splenectomy.
• Osteoporosis is very common and should be closely
monitored and treated to reduce risk of fractures and
comorbidities.
 Summary
• Ferritin underestimates the true iron load therefore
more definitive tests for iron assessment such as liver
biopsy or MRI need to be done to determine timing
and dosing of chelation.
• Transfusions play a key role in decreasing the IE and
subsequent complications and should be considered
early in the course of the disease before severe
complications arise.
• Splenectomy is less favourable due to the increased
complications post splenectomy.
• HbF augmentations agents may have a role to play in
reducing transfusion needs and raising hemoglobin.
 Case
• 42 yo immigrated from Albania
• Diagnosis of thalassemia made in early childhood
• No prior transfusions, No splenectomy
• Hemoglobin 70s, asymptomatic
• Cholecystectomy
• Recent minor fall: fracture L wrist, L pubic ramus
• Fully functional, office job, 1 son
• O/E: splenomegaly 2 cm below umbilicus, liver
span 16 cm
 Case
• Hgb 76, MCV 75, RDW 35.3
• WBC 4.7, platelets 156
• Hemoglobinopathy study:
– HbA 31.4%
– HbA2 3.4%
– HbF 59%
• Compound heterozygous
– IVS-T-110 G-A / poly-A AATAAA to AATGAA
– β+/β+
 Further work up
• Abdo US
– Liver 20 cm, spleen 23 cm
• EMH?
– CXR – No obvious mass
– MRI pending
• Iron loads
– Ferritin 664
– LIC – biopsy and liver MRI pending
– Cardiac MRI – T2* 31 ms (normal > 20ms)
• Cardiac complications?
– echo- - mildly dilated left atrium, no PHTN
– ECG – normal
• Bone disease? BMD
– T scores: Spine -3.7, L femoral neck -2.3