thalassaemia case scenarios
TRANSCRIPT
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Thalassaemia Case Scenarios Dr Emma Drašar
Consultant Haematologist UCLH and The Whittington NHS Trust
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With transfusion and chelation therapy, thalassemia patients can be expected to have a normal life, shifting the focus to managing the disease complications
IOL, iron overload; TDT, transfusion-dependent thalassemia.
Borgna-Pignatti C, et al. Haematologica. 2004;89:1187-93. Musallam KM, et al. Haematologica. 2013;98:833-44.
Non-transfusion-dependent thalassemias (NTDT)
β-thalassemia major (regularly transfused, TDT)
Silent cerebral ischemia
Pulmonary hypertension Right-sided heart failure
Splenomegaly
Gallstones
Hepatic fibrosis, cirrhosis, and cancer
Extramedullary hemopoietic pseudotumors
Leg ulcers
Venous thrombosis
Osteoporosis
Cardiac siderosis Left-sided heart failure
Hepatic failure Viral hepatitis
Diabetes mellitus
Hypogonadism
Hypothyroidism Hypoparathyroidism
Osteoporosis
Disease-related Disease- and IOL-related
Surv
ival
pro
bab
ility
p < 0.00005
0
1.00
0.75
0.50
0.25
0 5 10 15 20 25 30 Age (years)
Birth cohort
1960–1964 1965–1969 1970–1974 1975–1979 1980–1984 1985–1997
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Resources for the patient and the clinician
http://thalassaemia.org.cy/ http://www.ukts.org/
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Case 1
• 25 year old lady with TDT beta-thalassaemia major comes to clinic with her new husband
• They want to start a family
• How would you approach this?
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Case 1: Pre-conception counselling
• Risk of having an affected child (20-30/year thalassaemia in UK)
• Risk to mother – Previous history/severity
• Thalassaemia – Transfusion history – antibodies – Cardiac iron overload – Chelation
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Case 1: Risks to women with thalassaemia • Cardiac problems (cardiomyopathy and arrhythmias),
given the 40% increase in cardiac workload during pregnancy
• Worsening osteoporosis • Iron overload • Small stature – difficult labours • Infertility • Thrombosis – especially post splenectomy in intermedia
patients
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Case 1: Risks to the fetus
• The possibility of having a major haemoglobin disorder, depending on the globin genotype of the other parent
• If the mother has diabetes, there is a four-old increased risk of fetal anomaly and three-fold increase in perinatal mortality (NICE 2008)
• If ovulation induction results in a multiple pregnancy, there is increased risk of premature delivery, growth restriction, and disability in the infants.
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What do we do? PREPARATION! • Iron – and chelation thereof
– T2* >20ms and a liver iron as measured by Ferriscan of <5mg/g/dw and a serum ferritin close to 1000μg/L
– Stop chelation – desferral when preg test positive
• Hormones – insulin (OGTT) and thyroid function • Vitamins
– Vit D – Folic Acid
• Spleen – Vaccines
• Other medications
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What do we do? PREGNANCY • Refer to specialist for ovulation induction
– Clomifine – Gonadotrophins (if hypogonadal) – U/S and then HCG to trigger ovulation
• Reassess iron load at 28/40 and cardiology review - LVEF • Consider restarting desferral in 2nd or 3rd trimester
– T2* of <10ms should start on low dose subcutaneous desferrioxamine (20mg/kg/day) on a minimum of 4 to 5 days
– T2*> 10ms but < 20ms should be assessed for risks T2*>20ms no chelation unless there is a high risk of cardiac complications.
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What do we do? PREGNANCY and DELIVERY
• Joint specialist clinic – high risk pregnancy • Anticoagulation
– Aspirin +/- LMWH
• Keep Hb >100g/L trough • Monthly fructosamines • Remember allo antibodies!!! • Normal vaginal delivery is possible • Commence desferral when labour
commences
10
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Case 2: • Male patient 23 years old presents to A&E with
back pain • Found to have splenomegally and anaemia
– Hb 70g/L – Spleen 3 finger breadths below diaphragm
• Slightly thalassaemic features • Hb electophoresis shows HbF and HbA and raised
HbA2
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Case 2:
• Thalassaemia intermedia or poorly transfused thalassaemia major?
• Or TDT or NTDT?
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Case 2: NTDT • Treatment options in NTDT
– Hydroxyurea – New agents – luspatercept, suspatercept
• When to transfuse? • Role of chelation • Splenectomy? • What can modulate severity of NTDT? • Why might this chap have back pain?
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Case 3:
• 40 year old female TDT beta thalassaemia
• Presents with puffy face and increasing SOB
• Poorly tolerant to s/c desferral
PMH: splenectomy aged 5 years old, previous iron overload (now resolved)
What could be cause of symptoms?
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Case 3:
• Port-a-cath in situ for 7 years (4 previous ports)
• Stopped warfarin 7 months ago
• Significant thrombosis: Superior vena cava obstruction seen on venogram
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Case 3:Hypercoagulable state
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Case 3: What do we do?
• Avoid central lines if possible
• Anticoagulate all patients with indwelling lines
• Ask radiologist to make sure the tip of line is NOT in the right atrium
• Low threshold for imaging of patient presents with symptoms
• Avoid splenectomy
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Case 4: • 57 year old TM
– Presents with weight loss and diarrhoea – Investigate for diabetes ( negative, look for cancer-
negative, endoscopy and colonoscopy negative,)
• What to do now?? – Is this endocrine, thyroid normal, IGF1B reduced but
normal response on stimulation – Iron ( ferritin <500 ug/l now but not in the past!)
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Case 4:
• Side effects of drugs- deferiprone, deferasirox – Nausea vomiting diarrhea, stomach ulcers
• Pancreatic exocrine insufficiency – Presents with weight loss
– Diarrhoea
– Common in diabetes, cystic fibrosis, post operative, chronic pancreatitis settings, ETOH
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Case 4: Fecal elastase used to confirm diagnosis ( 200-99999 ug/g) – 100-200 is moderate insufficiency – Severe <100
• Treated with pancreatic enzyme replacement using Creon if symptomatic from moderate range downward – Dose often needs titrating upwards! And don’t forget
snacks….
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Any Questions?