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Indian Pediatr 2013;50:
929-933 |
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Efficacy of Fixed Low Dose Hydroxyurea in
Indian Children with Sickle Cell Anemia: A Single Centre
Experience
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Dipti L Jain, Mohini Apte, *Roshan Colah, Vijaya Sarathi, Saumil
Desai, Amruta Gokhale, Amol Bhandarwar, Harshwardhan L Jain and *Kanjaksha
Ghosh
From the Department of Pediatrics, Government Medical College,
Nagpur; and * National Institute of Immunohaematology,
Mumbai, India.
Correspondence to: Dr Dipti Jain,Professor, Department of Pediatrics,
Governement Medical College, Nagpur, Maharashtra 440 003, India.
Email: [email protected]
Received: January 19, 2013;
Initial review: February 06, 2013;
Accepted: March 12, 2013.
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Introduction: Data on the efficacy of hydroxyurea (HU) in Indian
children with sickle cell anaemia (SCA) is limited. Hence, we have
evaluated the efficacy of fixed low dose HU in Indian children.
Methods: The study cohort consisted of 144
children (<18 years of age) with SCA having severe manifestations ( ł3
episodes of vasocclusive crisis or blood transfusions, or having
ł1
episode of acute chest syndrome or cerebrovascular stroke or
sequestration crisis) who were started on fixed low dose HU (10
mg/kg/day). They were followed up for two years and monitored for the
hematological and clinical efficacy and safety.
Results: There was significant increase in the
fetal hemoglobin level (HbF%), total hemoglobin and mean corpuscular
volume. Vasoocclusive crises, blood transfusions, acute chest syndrome,
sequestration crises and hospitalizations decreased significantly.
Baseline HbF% had significant positive correlation with HbF% at 24
months. There was significant negative correlation between baseline HbF%
and change in HbF% from baseline to 24 months. No significant
correlation was found between HbF% at baseline and clinical event rates
per year after HU. No major adverse events occurred during the study
period.
Conclusion: Fixed low dose HU is effective and
safe in Indian children with SCA.
Keywords: Child, Hydroxyurea, India, Low dose, Sickle Cell
disease.
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Sickle cell disease is the most common
hemoglobinopathy in the world and is linked to five major haplotypes
[1]. The most common haplotype found in Indian sickle cell anemia (SCA)
patients is the Arab-Indian haplotype which is associated with high
baseline hemoglobin F (Hb F) levels [2-4]. Considerable clinical
diversity has been seen in Indian patients with SCA [3-5].
Hydroxyurea (HU) therapy has been shown to ameliorate
the severity of the disease in SCA, mainly by inducing HbF production
[6,7]. In SCA patients with African haplotypes, escalation of the dose
of HU to the maximal tolerated dose (MTD) significantly increases HbF
levels yielding a good clinical response [6,7]. Few studies have
demonstrated the clinical efficacy of HU in Indian patients with
relatively higher HbF levels [8,9]. We also recently demonstrated a good
clinical response to low fixed dose HU (10 mg/kg/day) in Indian SCA
children [10]; these studies were limited by small number of subjects.
It is believed that the severity of SCA is less in
those with high HbF [11]. Surprisingly, a significant proportion of
Indian SCA patients have severe manifestations despite high HbF levels
[4]. There is only one small study (25 children) which reports the
correlation between baseline HbF and hematological response to fixed low
dose HU in Indian children [8].
There are no studies that describe the correlation
between baseline HbF and clinical response to HU. Hence, we have
evaluated the clinical and hematological responses to HU in a large
cohort of Indian SCA children and their correlation with baseline HbF.
Methods
This prospective longitudinal study was conducted in
a tertiary health care center, Government Medical College, Nagpur.
Subjects were recruited between January 2005 and December 2009. The 30
subjects who received HU in our previous randomized controlled study
[10] were not included in this study. A written informed consent was
obtained from all subjects/parents/guardians. Approval from the
institutional ethics committee was procured prior to the start of the
study. Sickle cell anemia patients with
ł3 episodes of
vasoocclusive crisis or blood transfusions, ≥1 episode of acute
chest syndrome or cerebrovascular stroke or sequestration crisis were
enrolled for the study. Subjects with pregnancy, human immunodeficiency
virus infection, or medications that could potentially enhance HU
toxicity were excluded from the study. Other exclusion criteria were
serum creatinine above the upper limit of normal for age and serum
alanine aminotransferase (ALT) more than twice the upper limit of normal
for age at the time of entry.
Subjects were started on 10 mg/kg/day of HU (ONDERA
VHB, Mumbai). The liquid preparation of the HU is not available in India
and is available only as 500 mg capsules. The HU capsules were opened
and the required amount of the drug contents were weighted by a
pharmacist and provided in new packages. No dose escalation was done
irrespective of the clinical or hematological response. A clinical
proforma was used for follow up which was done every month. A detailed
clinical examination was done at each follow up. Laboratory
investigations including complete blood count, HbF percentage,
reticulocyte count, serum creatinine, aspartate aminotransferase (AST),
alanine aminotransferase (ALT) and serum bilirubin (total and direct)
were performed at the initiation of HU therapy and during each
subsequent visit. The number of vasoocclusive crises, blood
transfusions, cerebrovascular events (CVA), acute chest syndrome,
sequestration crises, acute febrile illnesses and hospitalisations
during the preceding one year and two years after initiation of HU were
documented. Patient compliance was measured by checking the number of
remaining capsules of HU during follow up visits. All the patients were
advised to take folic acid (5 mg/day) and ensure adequate fluid intake.
Only events for which the patient presented to the
hospital for medical care were recorded for analysis. A painful
event/crisis was defined as pain in the extremities, back, abdomen,
chest, or head for which no other explanation could be found. Severe
anemia was defined as a hemoglobin level less than 5 g/dL. Sequestration
crisis was defined as a decrease of the hemoglobin or hematocrit level
of at least 20% from baseline accompanied by an increase in palpated
spleen size of at least 2 cm from baseline. A febrile episode was
defined as a hospitalization with fever (
≥101ş
Fahrenheit). Confirmatory malarial diagnosis was defined as an
identification of malaria parasite in a peripheral blood smear.
Bacteremia was defined as an acute event with growth of bacteria in
blood culture samples. Meningitis was defined as abnormal cerebrospinal
fluid (CSF) findings and yield of pathogenic bacteria on CSF culture.
Acute chest syndrome was defined by the following three symptoms: fever,
tachypnea, and observation of new pulmonary infiltrates on X-ray.
Stroke or CVA was defined as an acute neurologic syndrome secondary to
the occlusion of an artery or to hemorrhage with resultant neurologic
symptoms and signs.
During the follow up, the drug was stopped
temporarily if ALT was elevated above two times the upper limit of
normal for age and serum creatinine was elevated above the upper limit
of the normal, reticulocyte count was <80,000/µl when the Hb was <9 g/dL,
absolute neutrophil count was < 1500/µL or platelet count was
<80,000/µL. The abnormal parameters were closely followed for recovery.
If recovery occurred, the drug was restarted at the same dose (10
mg/kg/day) with close monitoring for reappearance of side effects.
Complete blood count was done on the Sysmex K 1000
haematology counter. Reticulocyte count was done using brilliant cresyl
blue staining. Haemoglobin analysis was done on the Variant Haemoglobin
Testing System (BioRad Laboratories, Inc, Hercules, CA, USA). Renal and
liver function tests were performed using an autoanalyser.
Statistical analysis: Statistical analysis was
done with SPSS software version 16. Paired ‘t’ test was used to
compare the baseline findings with those after HU therapy at 24 months.
Pearson’s correlation coefficient (r) was used to calculate correlation
between two variables. A P<0.05 was considered statistically
significant.
Results
One hundred and forty four children with SCA (92
males and 52 females; age range: 3.5 to 17.9 years) were started on
hydroxyurea. There were no drop outs out of 144 children, followed for
two years. The mean age of the study population at the time of
registration in our sickle cell clinic was 6.7±3.3 years and the mean
age at which HU started was 13.8±4.7 years. The numbers of subjects with
various indications for initiation of HU are listed in Table I.
TABLE I Indications for Initiation of Hydroxyurea
Indications
|
Number of
|
|
subjects |
Vasoocclusive crises ≥3 |
113 |
Vasoocclusive crises ≥3 and blood
transfusion ≥3 |
4 |
Vasoocclusive crises ≥3 and stroke |
6 |
Vasoocclusive crises ≥3 and acute
chest syndrome |
3 |
Vasoocclusive crises ≥3 and
sequestration crises |
5 |
Blood transfusion ≥3 |
9 |
Stroke |
1 |
Acute chest syndrome |
1 |
Sequestration crisis |
1 |
Acute chest syndrome and sequestration crisis |
1 |
Hematological response: Hematological parameters
at the start of HU and at 24 months and clinical event rates per year
during the preceding year and 2 years after initiation of HU therapy are
shown in Table II. There was a significant increase in the
HbF levels from baseline to 24 months. Total hemoglobin and mean
corpuscular volume also increased significantly. There was significant
decrease in the leucocyte count, platelet count and reticuloyte count.
TABLE II Comparison of Clinical Event Rates per year and Hematological Parameters before and 24 months after
Hydroxyurea Therapy of the Whole Study Cohort
Character |
Baseline |
After 24 months HU |
P value |
Vasoocclusive crisis* |
4.27 ± 1.99 |
0.15 ± 0.47 |
<0.001 |
Blood transfusion* |
0.77 ± 1.33 |
0.15 ± 0.58 |
<0.001 |
Hospitalization* |
4.57 ± 1.77 |
0.29 ± 0.73 |
<0.001 |
Cerebrovascular event* |
0.04 ± 0.21
|
0.0 |
<0.001 |
Acute chest syndrome* |
0.03 ± 0.18 |
0.0 |
0.025 |
Sequestration crisis* |
0.04 ± 0.21 |
0.0 |
<0.001 |
Hemoglobin (g/dL) |
8.53 ± 1.74 |
9.66 ± 1.58 |
<0.001 |
Mean corpuscular volume (fl) |
79.21 ± 23.74 |
88.3 ± 11.10 |
<0.001 |
Leucocyte count ×1000/mm3 |
12.36 ± 8.92 |
8.79 ± 3.74 |
<0.001 |
Platelet count × 1000/mm3
|
244.23 ± 133.58 |
199.61 ± 124.72 |
0.004 |
Reticluocyte × 1000/mm3 |
258.2 ± 144.6 |
168.43 ± 123.5 |
<0.001 |
Hb F (%) |
16.45 ± 7.66 |
21.98 ± 5.22 |
<0.001 |
*event rates are defined per year. |
Clinical response: When compared to the event
rate before initiation of HU, there was a significant decrease in the
frequency of vasoocclusive crises, blood trans-fusions, sequestration
crises, stroke, acute chest syndromes and hospitalizations at 24 months.
Frequency of vasoocclusive crises was decreased by 96.4% and that of
blood transfusion by 79.3%. None of the subjects had stroke, acute chest
syndrome or sequestration crisis after initiation of HU. Frequency of
hospitalizations was also decreased by 93.5%.
Toxicity: Clinical adverse events in the study
subjects are listed in Web Table I. There were 21 episodes
of laboratory toxicities leading to hydroxyurea withdrawal (Web
Table II). The indications for HU withdrawal were abnormal liver
function (8 episodes in 6 patients), abnormal kidney functions (3
episodes in 2 patients), neutropenia (5 episodes in 4 patients),
thrombocytopenia (n= 4 episodes in 4 patients), acquired
immunodeficiency syndrome (1 patient). In 16 episodes of HU withdrawal,
the abnormalities were transient and HU could be restarted.
Correlation of Baseline HbF with clinical and
hematological response: Fetal hemoglobin response to HU was
variable. However, there was significant negative correlation between
baseline HbF levels with change in HbF levels from baseline to 24 months
(r = -0.61, P < 0.001) suggesting a higher increase in HbF levels
in patients with lower baseline HbF levels. Baseline HbF levels had a
significant positive correlation with HbF levels at 24 months (r = 0.78,
P <0.001) and baseline MCV (r = 0.31, P <0.001). There was
no significant correlation between baseline HbF levels with any other
baseline parameters or parameters at 24 months. Fetal hemoglobin levels
at 24 months had significant positive correlation with MCV at 24 months
(r = 0.22, P = 0.008). There were no significant correlations
between HbF levels at 24 months with any other parameters at baseline or
at 24 months.
Discussion
This study reports the hematological and clinical
efficacy of low fixed dose HU in a large number of Indian SCA children.
Many long term studies have clearly demonstrated the efficacy of HU in
African children with SCA [12,13]. There are very few studies which have
reported the efficacy of HU in Indian children with SCA who have higher
HbF compared to other population groups. We have recently reported the
efficacy of fixed low dose HU in a small number of SCA children in a
randomized controlled trial. In that study subjects had very severe
phenotypes with mean VOC rate of 12.13±8.56. The study clearly showed
the clinical benefits of this regimen along with lesser side effects
[10]. In the present study we have used the same regimen in a large
number of relatively less severe SCA children. This study has also
demonstrated significant clinical and hematological improvement with HU.
Similar to our previous study we did not escalate the dose of HU since
most of the possible benefit was observed with a low dose and this
regimen was proved to be associated with greater safety. A recent study
from eastern India has also demonstrated good efficacy of low fixed dose
HU (10 mg/kg/day) in SCA subjects. The frequency of painful crises was
reduced by 71.5% in pediatric cases. The efficacy was more in adults
with reduction of 92.2% of painful crises. Hydroxyurea therapy resulted
in transfusion independency in 95% of patients [14]. Few studies from
outside India have also documented the efficacy of low dose HU in SCA
patients [12,15,16]. There has been no direct comparison of fixed dose
to MTD in children or adults with SCA. Indirect comparison of multiple
studies that escalated to MTD compared to fixed dose or escalation to
clinical effect, supports greater improvement in beneficial laboratory
measures (increased total Hb concentration, Hb F, decreased WBC) in
children treated at the MTD [17]. Further studies with direct comparison
of fixed dose to MTD may provide better information on this issue.
In the present study, both the sickle cell related
events like painful events and other side effects like nausea/vomiting,
headache, diarrhea were less common than that in HUG-KIDS phase I/II
trial in which MTD of HU was used (Web Table I).
Laboratory toxicities like neutropenia, reticulocytopenia and
thrombocytopenia were also less common in our study than that in
HUG-KIDS phase I/II trial (Web Table II). Majority of the
laboratory toxicities in the HUG-KIDS phase I/II trial 6
were due to neutropenia (< 2000/µl) and in most of these cases the
neutrophil counts were between 1500-2000/µl. In our study, we have
defined neutropenia as < 1500/µl. This may be partly responsible for
disproportionately higher occurrence of neutropenia in the HUG-KIDS
study. Despite these differences laboratory toxicities in our study were
much less where we have used low fixed dose HU [6].
Even in BABY-HUG [18] study in which a low fixed
dose (20 mg/kg/day) of HU was used, the frequency of neutropenia was
much higher despite using a stricter definition of neutropenia (<1250).
Episodes of thrombocytopenia were also higher in
BABY-HUG study. Similar to our study, the frequency of reticulocytopenia
was very negligible in BABY-HUG study. Frequencies of ALT elevation in
our study were similar to those in HUG-KIDS and BABY-HUG studies.
However, unlike HUG-KIDS and BABY-HUG studies, there were 3 episodes of
creatinine elevation in our study. Two episodes in one patient were
attributed to recurrent urinary tract infection while the third episode
was associated with acute upper respiratory infection and decreased
fluid intake. Low fixed dose HU may require less frequent or no
laboratory monitoring and cause fewer episodes of cytopenia as seen with
20 mg/kg/day dose used in the BABY HUG Study and 10 mg/kg/day dose used
in our study. This may be particularly valuable in regions with limited
resources for health care [17].
There was a predominance of boys in our cohort. This
may be due to gender bias, still prevalent in our country, where boys
are brought more to health care than girls. This is reflected by a
higher number of boys registered in our sickle cell clinic. All our
patients were followed-up regularly which may be attributed to a
well-established sickle cell clinic for the last 20 years at our center.
All subjects were compliant to HU therapy. This may be attributed to the
free provision of the drug, large clinical benefits and lower toxicity
due to the fixed low dose regimen.
In the western population, HbF response was
considered as the gold standard to assess the response to HU. There are
many clinical and genetic predictors of HbF response to HU [19,20].
Baseline HbF levels is shown to predict HbF response to HU in few
studies [21, 22]. In the current study, baseline HbF levels had
significant positive correlation with HbF at 24 months suggesting
attainment of higher HbF levels in those who had higher baseline HbF
levels. However, there was a negative correlation between baseline HbF
levels with change in HbF levels from baseline to 24 months suggesting a
lesser increase in HbF levels in those children with higher baseline HbF
levels.
There was no significant correlation between baseline
HbF levels and frequency of vasoocclusive crises. This may be due to
selection of subjects with severe manifestations irrespective of
baseline HbF levels. There was no significant correlation between
frequency of vasoocclusive crises at 24 months and HbF levels at 24
months or change in HbF from baseline to 24 months. This may be due to
other mechanisms of action of HU which include improvement of the
rheological properties by decreasing the adhesiveness and absolute
number of neutrophils and reticulocytes, decrease in hemolysis by
improving hydration, causing macrocytosis and thereby hampering the
sickling mechanism and vasodilatation due to release of nitric oxide
[23]. This may also be due to very small number of vasoocclusive crises
occurring at 24 months.
In conclusion, low fixed dose HU (10 mg/kg/day)
causes significant increase in HbF levels with significant clinical
benefits in Indian children with SCA and is associated with lesser HU
associated laboratory toxicities.
Contributors: DLJ: was involved in study
planning, patient recruitment and patient management; MA, SD, AG, AB and
HLJ: were involved in patient recruitment, data collection and review of
literature; VS: was involved in review of literature, data analysis,
initial drafting of the manuscript; RC and KG: were involved in the
hematological investigations and critical review of the manuscript.
Funding: None; Competing interests: None
stated.
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