1. EHA & WFH HIGHLIGHTS July 30-31, 2010 Rest House Tyr Lebanon

2. THALASSEMIA INTERMEDIA TREATMENT STRATEGIES Ali Taher, M.D. American University of Beirut Medical Center Beirut - Lebanon Tyr | July 2010

3. THALASSEMIA INTERMEDIA REVISITED Part I

4. ●“Highly diverse” group of β-thalassemia syndromes where red blood cells are sufficiently short-lived to cause anemia but not necessarily the need for regular blood transfusions. ●Clinical phenotypes lie in severity between those of β-thalassemia minor and β-thalassemia major (TM). ●Arises from defective gene(s) leading to partial suppression of β-globin protein production. Presentation at age 2–6 years Retarded growth and development Completely asymptomatic until adult life Taher A, et al. Blood Cells Mol Dis. 2006;37:12-20. Guidelines for the clinical management of thalassaemia. 2nd rev ed. TIF 2008. β-Thalassemia intermedia (TI) SevereMild

5. Determinants of disease severity ●Molecular factors –inheritance of a mild or silent β-chain mutation –presence of a polymorphism for the enzyme Xmn-1 in the G  -promoter region, associated with increased HbF –co-inheritance of  -thalassaemia –increased production of  -globin chains by triplicated or quaduplicated  -genotype associated to β-heterozygosity; also from interaction of β- and δβ-thalassaemia ●Environmental factors may influence severity of symptoms, e.g. –social conditions –nutrition –availability of medical care Taher A, et al. Blood Cells Mol Dis. 2006;37:12-20.HbF = fetal hemoglobin.

6. Hemolysis Ineffective erythropoiesis Membrane binding of IgG and C3 Anemia Increased erythropoietin synthesis Skeletal deformities, osteopenia Erythroid marrow expansion Iron overload Splenomegaly Excess free α-globin chains Denaturation Degradation Formation of heme and hemichromes Iron-mediated toxicity Removal of damaged red cells Increased Iron absorption Reduced tissue oxygenation Pathophysiology summarized Olivieri NF, et al. N Engl J Med. 1999;341:99-109. Ineffective erythropoiesis Chronic anemia and hemolysis Iron overload Ineffective erythropoiesis Chronic anemia and hemolysis Iron overload

7. Prevalence of common complications in TI vs TM Complication (% of patients affected) TITM LebanonItalyLebanonItaly (n = 37)(n = 63)(n = 40)(n = 60) Splenectomy90679583 Cholecystectomy8568157 Gallstones55631023 Extramedullary hemopoiesis202400 Leg ulcers203300 Thrombotic events282200 Cardiopathy*351025 Pulmonary hypertension † 50171011 Abnormal liver enzymes20225568 HCV infection733798 Hypogonadism538093 Diabetes mellitus3212.510 Hypothyroidism321511 Taher A, et al. Blood Cells Mol Dis. 2006;37:12-20.HCV = hepatitis C virus. *Fractional shortening 30 mmHg; a well-enveloped tricuspid regurgitant jet velocity could be detected in only 20 patients, so frequency was assessed in these patients only.

8. Overview on Practices in Thalassemia Intermedia Management Aiming for Lowering Complication-rates Across a Region of Endemicity: the OPTIMAL CARE study ●Retrospective review of 584 TI patients from six comprehensive care centers in the Middle East and Italy Taher AT, et al. Blood. 2010 ;115:1886-92. N = 12 N = 127 N = 51 N = 153 N = 200 N = 41

9. Parameter Frequency n (%) Age (yrs) <18172 (29.5 ) 18-35288 (49.3) >35124 (21.2) Male : Female291 (49.8) : 293 (50.2) Splenectomized325 (55.7) Serum ferritin (ng/ml) <1000376 (64.4) 1000-2500179 (30.6) >250029 (5) Overall study population Complications Frequency n (%) Osteoporosis EMH Hypogonadism Cholelithiasis Thrombosis Pulmonary hypertension Abnormal liver function Leg ulcers Hypothyroidisim Heart failure Diabetes mellitus 134 (22.9) 124 (21.2) 101 (17.3) 100 (17.1) 82 (14) 64 (11) 57 (9.8) 46 (7.9) 33 (5.7) 25 (4.3) 10 (1.7) EMH = extramedullary hematopoiesis Taher AT, et al. Blood. 2010 ;115:1886-92.

10. 120 Treatment-naïve patients Age vs. hemoglobin level (rs=-0.679, P<0.001) Age vs. serum ferritin level (rs=0.653, P<0.001) Taher A, et al. Br J Haematol 2010. Epub ahead of print.

11. Complications vs. Age ●Complications in 120 treatment-naïve patients with TI * * * * * * * = statistically significant trend Taher A, et al. Br J Haematol 2010. Epub ahead of print.

12. TREATMENT OPTIONS Part I

13. Splenectomy ●Less common than in the past –before age 5 years it carries a high risk of infection and is therefore not generally recommended ●Main indications include –growth retardation or poor health –leukopenia –thrombocytopenia –increased transfusion demand –symptomatic splenomegaly ●Primarily done in regularly transfused TM patients Taher A, et al. Blood Cells Mol Dis. 2006;37:12-20. Guidelines for the clinical management of thalassaemia. 2nd rev ed. TIF 2008.

14. Cappellini MD, et al. Br J Haematol. 2000;111:467-73. Atichartakarn V, et al. Int J Hematol. 2003; 78:139-45. Pinna AD, et al. Surg Gynecol Obstet. 1988;167:109-13. Splenectomy: adverse events ●Thromboembolic events ●Pulmonary hypertension ●Infection –10-year follow-up of 221 splenectomized patients, 6 of whom died of sepsis –no need to “wait & see” in such patients with fever

15. In the OPTIMAL CARE study splenectomized patients: 325/584 ComplicationParameterRR95% CIp-value EMHSplenectomy0.440.26-0.730.001 Transfusion0.060.03-0.09<0.001 Hydroxyurea0.520.30-0.910.022 Pulmonary hypertension Age > 35 yrs2.591.08-6.190.032 Splenectomy4.111.99-8.47<0.001 Transfusion0.330.18-0.58<0.001 Hydroxyurea0.420.20-0.900.025 Iron chelation0.530.29-0.950.032 Heart failureTransfusion0.060.02-0.17<0.001 ThrombosisAge > 35 yrs2.601.39-4.870.003 Hb ≥ 9 g/dl0.410.23-0.710.001 Ferritin ≥ 1000 ng/ml1.861.09-3.160.023 Splenectomy6.593.09-14.05<0.001 Transfusion0.280.16-0.48<0.001 CholelithiasisAge > 35 yrs2.761.56-4.87<0.001 Female1.961.18-3.250.010 Splenectomy5.192.72-9.90<0.001 Transfusion0.360.21-0.62<0.001 Iron chelation0.300.18-0.51<0.001 Abnormal liver function Ferritin ≥ 1000 ng/ml1.741.00-3.020.049 Taher AT, et al. Blood. 2010 ;115:1886-92.EMH = extramedullary hematopoiesis.

16. ComplicationParameterRR95% CIp-value Leg UlcersAge > 35 yrs2.091.05-4.160.036 Splenectomy3.981.68-9.390.002 Transfusion0.390.20-0.760.006 Hydroxyurea0.100.02-0.430.002 HypothyroidismSplenectomy6.042.03-17.920.001 Hydroxyurea0.050.01-0.450.003 OsteoporosisAge > 35 yrs3.512.06-5.99<0.001 Female1.971.19-3.270.009 Splenectomy4.732.72-8.24<0.001 Transfusion3.101.64-5.85<0.001 Hydroxyurea0.020.01-0.09<0.001 Iron chelation0.400.24-0.680.001 HypogonadismFemale2.981.79-4.96<0.001 Ferritin ≥ 1000 ng/ml2.631.59-4.36<0.001 Transfusion16.134.85-52.63<0.001 Hydroxyurea4.322.49-7.49<0.001 Iron chelation2.511.48-4.260.001 In the OPTIMAL CARE study splenectomized patients: 325/584 Taher AT, et al. Blood. 2010 ;115:1886-92. Splenectomy was independently associated with an increased risk of most disease-related complications.

17. Representative examples of time course of thrombin generation in the presence of erythroid thalassemic cells as source of phospholipids 150 120 90 60 30 0 010306090120150 Time (seconds) Thrombin generation (nM) Splenectomized TI patients Non-splenectomized TI patients Normal controls Splenectomized controls Cappellini MD, et al. Br J Hematol. 2000;111:467–73. Reprinted with permission. Splenectomy vs. hypercoagulability Higher rates of prcoagulant RBCs and activated platelets in splenectomized patients. Taher A, et al. Blood Rev. 2008;22:283-92. Higher rates of prcoagulant RBCs and activated platelets in splenectomized patients. Taher A, et al. Blood Rev. 2008;22:283-92.

18. Thromboembolic events in a large cohort of TI patients ●Patients (N = 8,860) –6,670 with TM –2,190 with TI ●146 (1.65%) thrombotic events –61 (0.9%) with TM –85 (3.9%) with TI ●Risk factors for developing thrombosis in TI were –age (> 20 years) –previous thromboembolic event –family history –splenectomy Taher A, et al. Thromb Haemost. 2006;96:488-91. DVT = deep vein thrombosis; PE = pulmonary embolism; PVT = portal vein thrombosis; STP = superficial thrombophlebitis. Thromboembolic events (%) Type of event TM (n = 61) TI (n = 85)

19. 30 patients underwent brain MRI and PET scanning –18 (60%) had abnormal MRI findings –19 (63.3%) had abnormal PET findings –26 (86.7%) had abnormal MRI, abnormal PET, or both MRI = magnetic resonance imaging; PET = positron emission tomography. Asymptomatic brain damage in splenectomized adults with TI Taher AT, et al. J Thromb Haemot. 2010;8:54-9. Taher AT, et al. Blood (ASH Annual Meeting Abstracts), 2009; 114 (22): 4077.

20. Splenectomy vs. thrombosis in the OPTIMAL CARE study ●Three Groups of patients were identified: Group I, splenectomized patients with a documented TEE (n = 73); Group II, age- and sex- matched splenectomized patients without TEE (n = 73); and Group III, age- and sex-matched non-splenectomized patients without TEE (n = 73) Taher A, et al. J Thromb Haemost. 2010. Epub ahead of print. Type of thromboembolic eventn (%) DVT, n (%)46 (63.0) PE*, n (%)13 (17.8) STP, n (%)12 (16.4) PVT, n (%)11 (15.1) Stroke, n (%)4 (5.5) *All patients who had PE had confirmed DVT DVT = deep vein thrombosis; PE = pulmonary embolism; STP = superficial thrombophlebitis; PVT = portal vein thrombosis

21. Parameter Group I Splenectomized with TEE n = 73 Group II Splenectomized without TEE n = 73 Group III Non- splenectomized n = 73 P-value Mean age ± SD, years33.1 ± 11.733.3 ± 11.933.4 ± 13.1 0.991 Male: Female33:4035:3834:390.946 Mean Hb ± SD, g/dl9.0 ± 1.38.8 ± 1.28.7 ± 1.3 0.174 Mean HbF ± SD, %45.9 ± 28.054.4 ± 32.844.2 ± 27.2 0.429 Mean NRBC count ± SD, x10 6 /l436.5 ± 205.5279.0 ± 105.2239.5 ± 128.7 <0.001 Mean platelet count ± SD, x10 9 /l712.6 ± 192.5506.3 ± 142.1319.2 ± 122.0 <0.001 PHT, n (%)25 (34.2)17 (23.3)3 (4.1)<0.001 HF, n (%)7 (9.6)5 (6.8)1 (1.4)0.101 DM, n (%)4 (5.5)5 (6.8)1 (1.4)0.256 Abnormal liver function, n (%)2 (2.7) 3 (4.1)0.863 Family history of TEE3 (4.7)1 (1.4)3 (4.7)0.554 Thrombophilia, n (%)3 (4.7)2 (2.7) 0.863 Malignancy, n (%)1 (1.4)2 (2.7)0 (0)0.363 Transfused, n (%)32 (43.8)48 (65.8)54 (74.0)0.001 Antiplatelet or anticoagulant use, n (%)1 (1.4)3 (4.1)2 (2.7)0.598 Hydroxyurea use, n (%)13 (17.8)17 (23.3)29 (27.4)0.383 Comparative analysis TEE = thromboembolic events; Hb = total hemoglobin; NRBC = nucleated red blood cell; HbF = fetal hemoglobin; PHT = pulmonary hypertension; HF = heart failure; DM = diabetes mellitus. Taher A, et al. J Thromb Haemost. 2010. Epub ahead of print.

22. ParameterGroupOR95% CIP-value NRBC count ≥ 300 x 10 6 /lGroup III1.00Referent <0.001 Group II5.352.31-12.35 Group I11.113.85-32.26 Platelet count ≥ 500 x 10 9 /lGroup III1.00Referent <0.001 Group II8.703.14-23.81 Group I76.9222.22-250.00 PHTGroup III1.00Referent 0.020 Group II4.000.99-16.13 Group I7.301.60-33.33 Transfusion naivetyGroup III1.00Referent 0.001 Group II1.670.82-3.38 Group I3.641.82-7.30 Multivariate analysis Group I had significantly higher NRBC, platelets, PHT occurrence, and were mostly non-transfused. NRBC = nucleated red blood cell; PHT = pulmonary hypertension; OR = adjusted odds ratio; CI = confidence interval. Taher A, et al. J Thromb Haemost. 2010. Epub ahead of print.

23. Time-to-thrombosis (TTT) since splenectomy The median TTT following splenectomy was 8 years (range, 1-33 years) The median TTT was significantly shorter in patients with a NRBC count ≥ 300 x 10 6 /l, a platelet count ≥ 500 x 10 9 /l, and who were transfusion naïve. Taher A, et al. J Thromb Haemost. 2010. Epub ahead of print. The median TTT following splenectomy was 8 years (range, 1-33 years) The median TTT was significantly shorter in patients with a NRBC count ≥ 300 x 10 6 /l, a platelet count ≥ 500 x 10 9 /l, and who were transfusion naïve. Taher A, et al. J Thromb Haemost. 2010. Epub ahead of print.

24. Anticoagulants in TI The available data on the use of anticoagulants, antiplatelet, or other agents in β-thalassemia are either lacking or involve small, poorly controlled and/or relatively low-quality studies. Taher AT, et al. Thromb Hemost 2006;96:488-91.

25. Current evidence for the benefit of transfusions in TI ●Failure to thrive in childhood in the presence of significant anemia ●Increasing anemia not attributable to rectifiable factors ●Delayed or poor pubertal growth spurt ●Progressive splenic enlargement ●Evidence of –bone deformities –clinically relevant tendency to thrombosis –leg ulcers –EMH –pulmonary hypertension ●Prior to surgical procedures Guidelines for the clinical management of thalassaemia. 2nd rev ed. TIF 2008.

26. ComplicationParameterRR95% CIp-value EMHSplenectomy0.440.26-0.730.001 Transfusion0.060.03-0.09<0.001 Hydroxyurea0.520.30-0.910.022 Pulmonary hypertension Age > 35 yrs2.591.08-6.190.032 Splenectomy4.111.99-8.47<0.001 Transfusion0.330.18-0.58<0.001 Hydroxyurea0.420.20-0.900.025 Iron chelation0.530.29-0.950.032 Heart failureTransfusion0.060.02-0.17<0.001 ThrombosisAge > 35 yrs2.601.39-4.870.003 Hb ≥ 9 g/dl0.410.23-0.710.001 Ferritin ≥ 1000 ng/ml1.861.09-3.160.023 Splenectomy6.593.09-14.05<0.001 Transfusion0.280.16-0.48<0.001 CholelithiasisAge > 35 yrs2.761.56-4.87<0.001 Female1.961.18-3.250.010 Splenectomy5.192.72-9.90<0.001 Transfusion0.360.21-0.62<0.001 Iron chelation0.300.18-0.51<0.001 Abnormal liver function Ferritin ≥ 1000 ng/ml1.741.00-3.020.049 In the OPTIMAL CARE study Occasionally-regularly transfused patients: 445/584 Taher AT, et al. Blood. 2010 ;115:1886-92.

27. ComplicationParameterRR95% CIp-value Leg UlcersAge > 35 yrs2.091.05-4.160.036 Splenectomy3.981.68-9.390.002 Transfusion0.390.20-0.760.006 Hydroxyurea0.100.02-0.430.002 HypothyroidismSplenectomy6.042.03-17.920.001 Hydroxyurea0.050.01-0.450.003 OsteoporosisAge > 35 yrs3.512.06-5.99<0.001 Female1.971.19-3.270.009 Splenectomy4.732.72-8.24<0.001 Transfusion3.101.64-5.85<0.001 Hydroxyurea0.020.01-0.09<0.001 Iron chelation0.400.24-0.680.001 HypogonadismFemale2.981.79-4.96<0.001 Ferritin ≥ 1000 ng/ml2.631.59-4.36<0.001 Transfusion16.134.85-52.63<0.001 Hydroxyurea4.322.49-7.49<0.001 Iron chelation2.511.48-4.260.001 In the OPTIMAL CARE study Occasionally-regularly transfused patients: 445/584 Only significant associations presented Taher AT, et al. Blood. 2010 ;115:1886-92. Transfusion therapy was protective for thrombosis, EMH, PHT, HF, cholelithiasis, and leg ulcers. Transfusion therapy was associated with an increased risk of endcorinopathy. Transfusion therapy was protective for thrombosis, EMH, PHT, HF, cholelithiasis, and leg ulcers. Transfusion therapy was associated with an increased risk of endcorinopathy.

28. ≤ 30 30–40 40–50 > 50 Age and transfusion history vs no. of abnormalities Probability of abnormality vs age Probability of abnormality Age (years) Non-transfused Occasionally transfused Patients (n) 0 1 2 3 4 5 6 Age (years) No. of abnormalities 0> 11 1015202530354045505560 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 0 1 2 3 4 5 6 Transfusion-naive patients had higher incidence and multiplicity of lesions Taher AT, et al. J Thromb Haemot. 2010;8:54-9. Asymptomatic brain damage

29. Cossu P, et al. Eur J Pediatr. 1981;137:267-71. Origa R, et al. Br J Hematol. 2007;136:326-32. Pippard MJ, et al. Lancet. 1979;2:819-21. Iron overload Iron overload occurs even in TI patients who have not been transfused - iron loading: 2–5 g Fe/year; iron toxicity develops from age 5 years Is much lower than in age-matched patients with transfusion-dependent TM Although the rate of iron loading differs between TM and TI, the consequences are apparent in both groups of patients and include - Liver - Heart (?long-term) - endocrine organs

30. ↑ Duodenal iron absorption ↑ Ferroportin ↑ Release of recycled iron from RES macrophages ↑ Erythropoietin Ineffective erythropoiesis Chronic anemia Hypoxia ↑ GDF15 ↑ HIFs ↓ Hepcidin ↑ LIC ↓ Serum ferritin Mechanism of iron overload in non-transfused patients Taher A, et al. Br J Haematol.2009;147:634-40. GDF15 = growth differentiation factor 15; HIF = hypoxia-inducible transcription factor.

31. 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 05101520253035404550 LIC (mg Fe/g dry wt) Serum ferritin level (μg/L) TITM Linear (TI) Linear (TM) Serum ferritin underestimates iron burden in TI Taher A, et al. Haematologica. 2008;93:1584-86. LIC correlated with serum ferritin levels in patients with TI (R = 0.64; p < 0.001) 0 A significant positive correlation with serum ferritin levels was observed (R = 0.64; p < 0.001). LIC values were similar to those in patients with TM, but serum ferritin levels were significantly lower. A significant positive correlation with serum ferritin levels was observed (R = 0.64; p < 0.001). LIC values were similar to those in patients with TM, but serum ferritin levels were significantly lower.

32. Age < 4 years Observation Age ≥ 4 years Hemoglobin < 9 g/dl Initiate transfusions Transfusions > 10 Units Start iron chelation therapy Monitor LIC and serum ferritin LIC > 7 mg Fe/g dw, or serum ferritin > 500 ng/ml Start iron chelation therapy Hemoglobin ≥ 9 g/dl Continue observation Monitor LIC and serum ferritin LIC > 7 mg Fe/g dw, or serum ferritin > 500 ng/ml Start iron chelation therapy Recommendations for iron chelation therapy in TI Taher A, et al. Br J Haematol.2009;147:634-40.

33. ComplicationParameterRR95% CIp-value EMHSplenectomy0.440.26-0.730.001 Transfusion0.060.03-0.09<0.001 Hydroxyurea0.520.30-0.910.022 Pulmonary hypertension Age > 35 yrs2.591.08-6.190.032 Splenectomy4.111.99-8.47<0.001 Transfusion0.330.18-0.58<0.001 Hydroxyurea0.420.20-0.900.025 Iron chelation0.530.29-0.950.032 Heart failureTransfusion0.060.02-0.17<0.001 ThrombosisAge > 35 yrs2.601.39-4.870.003 Hb ≥ 9 g/dl0.410.23-0.710.001 Ferritin ≥ 1000 ng/ml1.861.09-3.160.023 Splenectomy6.593.09-14.05<0.001 Transfusion0.280.16-0.48<0.001 CholelithiasisAge > 35 yrs2.761.56-4.87<0.001 Female1.961.18-3.250.010 Splenectomy5.192.72-9.90<0.001 Transfusion0.360.21-0.62<0.001 Iron chelation0.300.18-0.51<0.001 Abnormal liver function Ferritin ≥ 1000 ng/ml1.741.00-3.020.049 In the OPTIMAL CARE study Chelated patients: 336/584 Taher AT, et al. Blood. 2010 ;115:1886-92.

34. ComplicationParameterRR95% CIp-value Leg UlcersAge > 35 yrs2.091.05-4.160.036 Splenectomy3.981.68-9.390.002 Transfusion0.390.20-0.760.006 Hydroxyurea0.100.02-0.430.002 HypothyroidismSplenectomy6.042.03-17.920.001 Hydroxyurea0.050.01-0.450.003 OsteoporosisAge > 35 yrs3.512.06-5.99<0.001 Female1.971.19-3.270.009 Splenectomy4.732.72-8.24<0.001 Transfusion3.101.64-5.85<0.001 Hydroxyurea0.020.01-0.09<0.001 Iron chelation0.400.24-0.680.001 HypogonadismFemale2.981.79-4.96<0.001 Ferritin ≥ 1000 ng/ml2.631.59-4.36<0.001 Transfusion16.134.85-52.63<0.001 Hydroxyurea4.322.49-7.49<0.001 Iron chelation2.511.48-4.260.001 In the OPTIMAL CARE study Chelated patients: 336/584 Taher AT, et al. Blood. 2010 ;115:1886-92. Iron chelathion therapy was protective for hypogonadism, PHT, cholelithiasis, and osteoporosis.

35. 1 Cossu P, et al. Eur J Pediatr. 1981;137:267-71. 2 Pootrakul P, et al. Br J Hematol. 2003;122:305-10. ●Deferoxamine 1 –significant decline in serum ferritin after 6 months of deferoxamine treatment –significant UIE after 12 hours of continuous deferoxamine (except in patients aged < 1 year) in some patients, substantial UIE despite modest serum ferritin levels serum ferritin levels of no value in predicting UIE no significant differences in excretion across doses ●Deferiprone 2 –significant reductions seen in mean serum ferritin, hepatic iron, red-cell membrane iron, and serum NTBI levels –serum ferritin ± SD: initial 2,168 ± 1,142 μg/L; final 418 ± 247 μg/L –significant mean increase in serum erythropoietin also observed –increase in Hb values in 3 patients; reduction in transfusion requirements in 4 patients UIE = urinary iron excretion. Iron chelation therapy

36. Reduction in iron burden with deferasirox at year 1 in patients with TI Mean cardiac T2* and LVEF (both normal at baseline), serum creatinine, and cystatin C did not significantly change after 12 months of treatment with deferasirox Mean valuesBaseline12 monthsP-value Serum ferritin, µg/L2030 ± 13401165 ± 684.02 Liver T2, ms20.1 ± 4.123.7 ± 6.2.01 Liver T2*, ms3.4 ± 3.04.4 ± 3.0.02 Cardiac T2*, ms38.9 ± 5.939.8 ± 4.5.64 LVEF, %66.3 ± 8.166.9 ± 7.9.76 Aspartate aminotransferase, U/L64.8 ± 29.642.5 ± 18.1.04 Alanine aminotransferase, U/L63.5 ± 29.536.5 ± 17.6.02 Serum creatinine, mg/dL0.67 ± 0.150.75 ± 0.19.07 Cystatin C, mg/L0.98 ± 0.231.13 ± 0.27.094 Deferasirox can effectively reduce iron burden in patients with TI Voskaridou E, et al. Br J Haematol 2010;148:332-4.

37. Deferasirox for nontransfusional iron overload in patients with TI ● 11 patients with thalassemia intermedia –6 male, 5 female –Mean age 31.7 years –10 splenectomized ● Deferasirox regimen –1 year (n = 11), 2 years (n = 4) –10 mg/kg/day (n = 7), 20 mg/kg/day (n = 4) –Dose adjustment after first year Ladis V, et al. Haematologica. 2009;94(suppl 2):509(abstr 1279).

38. Effect of deferasirox on serum ferritin and LIC in patients with TI and nontransfusional iron overload Serum ferritin at baseline Serum ferritin at 1 year Serum ferritin at 2 years LIC at baseline LIC at 1 year LIC at 2 years With permission from Ladis V, et al. Haematologica. 2009;94(suppl 2):509(abstr 1279). 0 1000 2000 3000 Serum Ferritin Levels (ng/mL) Patients 0 10 20 40 LIC (mg Fe/g dry weight) 30 Patients ●1 patient, who was noncompliant, did not show decrease of iron overload and was excluded from graph ●Changes in LIC and ferritin levels were related to deferasirox dose, but even patients with severe iron load, treated with 10 mg/kg/day, responded well

39. Ladis V, et al. Haematologica. 2009;94(suppl 2):509(abstr 1279). Safety of deferasirox during treatment of up to 2 years ●Treatment was well tolerated –No serious adverse events were noted ●Creatinine and cystatin C levels did not change during treatment ●Transaminase levels significantly decreased in year 1 (P =.0002) and year 2 (P =.024) of treatment –This improvement probably due to decreased hepatic siderosis

40. Ongoing clinical evaluation of deferasirox in TI ●Prospective, randomized, double-blind, placebo-controlled trial ●Patients (age ≥10 years) with non–transfusion-dependent β-thalassemia (no transfusion required within 6 months prior to the study) ●2 doses: 5 mg/kg/day and 10 mg/kg/day ●Screening 4 weeks; treatment period 52 weeks ●Primary objective –To assess the efficacy of deferasirox in patients with non–transfusion-dependent β-thalassemia, based on the change in LIC from baseline after 1 year of treatment compared with placebo-treated patients Ali T. Taher, MD, principal investigator; Study ID ICL670A2209. Taher AT, et al. Blood (ASH Annual Meeting Abstracts), 2009; 114 (22):5111.

41. Modulation of fetal hemoglobin production ●The clinical picture of TI could be greatly improved by an even partial reduction in the degree of the non-α to α globin chain imbalance. ●Several drugs have been tried in an attempt to reactivate γ-chain synthesis and HbF production: 5-azacytidine, Hydroxycarbamide Erythropoietin Butyric acid derivatives Hemin ●Results are encouraging especially with combined therapy Borgna-Pignatti C. Br J Haematol. 2007;138:291–304.

42. Hydroxycarbamide ●Experience from Iran and India –most patients were reported to have become transfusion- independent –in patients who were not transfused, the Hb concentration increased –the combination of hydroxycarbamide with L-carnitine or magnesium could be more effective in improving hematologic parameters and cardiac status in patients with TI than hydroxyurea alone ●Experience from Europe –constant increase of the erythrocyte volume and in HbF, but only a modest effect on total Hb concentration Karimi M, et al. J Pediatr Hematol Oncol. 2005;27:380-5. Dixit A, et al. Ann Hematol. 2005;84:441-6. Karimi M, et al. Eur J Haematol. 2010;84:52-8.

43. Hydroxycarbamide (Cont’d) ●Co-inheritance of α-thalassemia, the Xmn-1 HBG2 polymorphism, and the underlying β- globin genotype may be predictive of a good response to hydroxycarbamide; Hb E/β- thalassemia patients generally have a good response ●Treatment with hydroxycarbamide has also shown promising results in decreasing plasma markers of thrombin generation Singer ST, et al. Br J Haematol. 2005;131:378-88. Panigrahi I, et al. Hematology. 2005;10:61-3. Ataga KI, et al. Br J Haematol. 2007;139:3-13.

44. In the OPTIMAL CARE study Patients on hydroxyurea: 202/584 ComplicationParameterRR95% CIp-value EMHSplenectomy0.440.26-0.730.001 Transfusion0.060.03-0.09<0.001 Hydroxyurea0.520.30-0.910.022 Pulmonary hypertension Age > 35 yrs2.591.08-6.190.032 Splenectomy4.111.99-8.47<0.001 Transfusion0.330.18-0.58<0.001 Hydroxyurea0.420.20-0.900.025 Iron chelation0.530.29-0.950.032 Heart failureTransfusion0.060.02-0.17<0.001 ThrombosisAge > 35 yrs2.601.39-4.870.003 Hb ≥ 9 g/dl0.410.23-0.710.001 Ferritin ≥ 1000 ng/ml1.861.09-3.160.023 Splenectomy6.593.09-14.05<0.001 Transfusion0.280.16-0.48<0.001 CholelithiasisAge > 35 yrs2.761.56-4.87<0.001 Female1.961.18-3.250.010 Splenectomy5.192.72-9.90<0.001 Transfusion0.360.21-0.62<0.001 Iron chelation0.300.18-0.51<0.001 Abnormal liver function Ferritin ≥ 1000 ng/ml1.741.00-3.020.049 Taher AT, et al. Blood. 2010 ;115:1886-92.EMH = extramedullary hematopoiesis.

45. ComplicationParameterRR95% CIp-value Leg UlcersAge > 35 yrs2.091.05-4.160.036 Splenectomy3.981.68-9.390.002 Transfusion0.390.20-0.760.006 Hydroxyurea0.100.02-0.430.002 HypothyroidismSplenectomy6.042.03-17.920.001 Hydroxyurea0.050.01-0.450.003 OsteoporosisAge > 35 yrs3.512.06-5.99<0.001 Female1.971.19-3.270.009 Splenectomy4.732.72-8.24<0.001 Transfusion3.101.64-5.85<0.001 Hydroxyurea0.020.01-0.09<0.001 Iron chelation0.400.24-0.680.001 HypogonadismFemale2.981.79-4.96<0.001 Ferritin ≥ 1000 ng/ml2.631.59-4.36<0.001 Transfusion16.134.85-52.63<0.001 Hydroxyurea4.322.49-7.49<0.001 Iron chelation2.511.48-4.260.001 In the OPTIMAL CARE study Patients on hydroxyurea: 202/584 Taher AT, et al. Blood. 2010 ;115:1886-92. Hydroxyurea treatment was protective for EMH, PHT, leg ulcers, hypothyroidism, and osteoporosis.

46. OPTIMAL CARE Multimodality therapy Mean number of complications 0.831.311.302.000.852.021.542.43 Iron chelation Transfusion Hydroxyurea Y Y YN N YN N Y YN N YN Taher AT, et al. Blood. 2010 ;115:1886-92.

47. Take-home message ●Our understanding of the molecular basis and pathophysiology of TI significantly increased ●Iron overload and hypercoagulability are recently receiving increasing attention in TI ●Despite various treatment options are available, no clear guidelines exist ●Several studies are challenging the role of splenectomy yet highlighting the benefit of transfusion, iron chelation therapy, and fetal hemoglobin induction in the management of TI; thus these approaches merit large prospective evaluation ●The role of antiplatelets/anticoagulants in TI merits investigation