Health Maintenance and Education for Children and Adults

Transcription

1 Health Maintenance and Education for Children and Adults Richard Ward, MSc, MRCP, FRCPath Director, Red Blood Cell Disorders Program, UHN Assistant Professor, Hematology, University of Toronto Chair, Canadian Hemoglobinopathy Association

2 Objectives 1. What are the key aspects of managing a patient with sickle cell disease across their lifespan? 2. What complications should I be aware of and how do I manage them? 3. How can services best be developed for patients with SCD? Infections in childhood, and beyond Wellness and health maintenance surveillance Multidisciplinary teamwork Chronic pain management Stroke prevention and iron overload strategies

3 SCD Then and Now >10% children suffer a stroke, 25% of adults High rate of childhood death from infections =NBS! Quinn, et al., Blood 2010

4 What are the vaso-occlusive manifestations of SCD? Vaso-occlusive Pain Stroke Acute Chest Syndrome Avascular necrosis Functional asplenia Hepatic sequestration Retinopathy Gladwin et al, NEJM 2008

5 What are the hemolytic manifestations of SCD? Anemia Pulmonary Hypertension Leg Ulcers Priapism Cerebral Vasculopathy Cholelithiasis

6 What are the infectious manifestations of SCD? Viral induced aplastic anemia Infection from encapsulated organisms: Pneumonia Meningitis S. pneumonia, H. influenzae, N. meningitides Septic Arthritis or Osteomyelitis: (Salmonella common organism) Urinary tract Infection Gladwin et al, NEJM 2008

7 Sickle Cell Disease is for Life Definition of for life has changed?

8 Detect and Prevent/Treat SCD Morbidity SCD is a poster child for multisystem diseases Brain Eyes Tonsils Lungs Heart Kidneys Fertility Liver Spleen Skin Bones

9 21 st Century Goals of Care for SCD Patient self-management Reduced hospital dependence Social, financial and emotional wellbeing Monitoring and treatment of complications Normal life expectancy

10 Therapeutic Tools at Our Disposal

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12 Multidisciplinary Team Nurse Practitioners Social Worker Physicians Trainees Administrative Nursing Manager Clerical Data Manager Medical Day Unit Nursing Team

13 Collaboration Combined cardiac Combined endocrine Neurology Ophthalmology Nephrology Urology Obstetric Infectious Diseases Community partners : uhn rbcd

14 Assessment of New Referral #1 Up to date contact info and list of providers Acute complications (pain) Analgesia use Chronic morbidity (head to toe) Red flags Acute Chest Syndrome Stroke ICU admission Exchange transfusion Therapies Hydroxyurea Transfusions +/- chelation Socio-economic history

15 Assessment of New Referral #2 Investigations Labs, Urinalysis ECHO, ECG Bone mineral density scan MRI brain +/- Liver MRI for LIC Therapies Immunisations Analgesia Hydroxyurea Transfusions +/- chelation Follow-Up q1w q6m

16 Neurological Events in SCD Moyamoya TIA Overt Stroke Silent Cerebral Infarct Vasculopathy

17 Effects of Silent Infarcts and Stroke on Cognitive Function

18 Stroke type and prevalence differ between pediatric and adult population Infarctive Hemorrhagic Ohene-Frempong K, Weiner SJ, Sleeper LA, et al. Cerebrovascular accidents in sickle cell disease: rates and risk factors. Blood Jan 1;91(1):

19 Early Detection of Increased Risk for Stroke Transcranial Doppler (TCD) Measures peak velocity blood flow in MCA by ultrasound High velocity = stenosis and vasculopathy > 170 cm/s (conditional) > 200 cm/s (abnormal) associated with 40% risk of stroke within 3 years Adams RJ. Big strokes in small persons. Arch Neurol Nov;64(11):

20 STOP Study Results Study or Subgroup Transfusion No Transfusion Odds Ratio Odds Ratio Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Adams % 0.07 [0.01, 0.53] Total (95% CI) % 0.07 [0.01, 0.53] Total events Heterogeneity: Not applicable Test for overall effect: Z = 2.56 (P = 0.01) RR = ARR = RRR = NNT = Favours transfusion Other NNTs for Comparisons Favours no transfusion Compression stockings prevent VTE 9 (7 13) Anti-hypertensives preventing CV 18 (14 25) ASA preventing CV death post-mi 40 Adams RJ, McKie VC, Hsu L, et al. Prevention of a first stroke by transfusions in children with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography. N Engl J Med Jul 2;339(1):5-11

21 STOP2 Study Results Study or Subgroup Continued Transfusion Transfusion Halted Odds Ratio Odds Ratio Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Adams % 0.02 [0.00, 0.35] Total (95% CI) % 0.02 [0.00, 0.35] Total events 0 Heterogeneity: Not applicable Test for overall effect: Z = 2.68 (P = 0.007) Favours Transfusion Favours No Transfusion Adams RJ, Brambilla D. Discontinuing prophylactic transfusions used to prevent stroke in sickle cell disease. The New England journal of medicine 2005;353(26):

22 SWiTCH Study Results Study or Subgroup Ware 2011 Hydroxyurea + Phlebotomy Transfusion + Chelation Odds Ratio Odds Ratio Events 7 Total 67 Events 0 Total 66 Weight 100.0% M-H, Fixed, 95% CI [0.92, ] M-H, Fixed, 95% CI Total (95% CI) Total events 7 Heterogeneity: Not applicable Test for overall effect: Z = 1.90 (P = 0.06) % [0.92, ] Hydroxyurea + Phlebotomy Transfusion + Chelation No difference in LIC Hydroxyurea + Phlebotomy (N = 67) Transfusion + Chelation (N = 66) P value Median IQR * Wilcoxon rank sum test due to non-normal distribution of LIC

23 Hydroxyurea Mode of Action 1. Increase in HbF production; 2-3. Decrease in White Blood Cell numbers and stickiness; 4. Stops dehydration of RBCs; 5. Helps mop up toxins from breakdown of RBCs

24 Development of Hydroxyurea

25 Mulitcentre Study of Hydroxyurea, 1995 Charache, S., et al. (1995). NEJM 332(20):

26 Indications for Hydroxyurea Classical (MSH Study) >3 pain episodes / yr >1 ACS Current All patients with HbSS - Prevention of end-organ damage / survival benefit HbSC with high HbF, low HCT and symptoms Jehovah s Witnesses Dosing To maximum tolerated dose Monthly reviews whilst titrating

27 Side Effects/Concerns

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31 Gluckman, Hematology ASH Education Book, 2013 Curative Therapies