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Background Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are oral alternatives to current standard-of-care treatments for anaemia in chronic kidney disease (CKD). We conducted network meta-analyses to indirectly compare clinical outcomes for three HIF-PHIs in dialysis and non-dialysis populations with anaemia in CKD. Methods The evidence base comprised phase III, randomised, controlled trials evaluating daprodustat, roxadustat, or vadadustat. Three outcomes were evaluated: efficacy (change from baseline in haemoglobin [Hgb]), cardiovascular safety (time to first major adverse cardiovascular event [MACE]) and quality of life (change from baseline in 36-Item Short Form Health Survey [SF-36] Vitality score). Analyses were performed separately for all patients and for erythropoiesis-stimulating agent (ESA) non-users at baseline (non-dialysis population) or prevalent dialysis patients (dialysis population). Bayesian Markov Chain Monte Carlo methods with non-informative priors were used to estimate the posterior probability distribution and generate pairwise treatment comparisons. Point estimates (medians of posterior distributions) and 95% credible intervals (CrI) were calculated. Results Seventeen trials were included. In non-dialysis patients, there were no clinically meaningful differences between the three HIF-PHIs with respect to Hgb change from baseline (all patients analysis [total n=7907]: daprodustat vs. roxadustat, 0.09 g/dL [95% CrI -0.14, 0.31]; daprodustat vs. vadadustat, 0.09 g/dL [-0.04, 0.21]; roxadustat vs. vadadustat, 0.00 g/dL [-0.22, 0.22]) or risk of MACE (all patients analysis [total n=7959]: daprodustat vs. roxadustat, hazard ratio [HR] 1.16 [95% CrI 0.76, 1.77]; daprodustat vs. vadadustat, 0.88 [0.71, 1.09]; roxadustat vs. vadadustat, 0.76 [0.50, 1.16]). Daprodustat showed a greater increase in SF-36 Vitality compared with roxadustat (total n=4880; treatment difference 4.70 points [95% CrI 0.08, 9.31]). In dialysis patients, Hgb change from baseline was higher with daprodustat and roxadustat compared with vadadustat (all patients analysis [total n=11 124]: daprodustat, 0.34 g/dL [0.22, 0.45]; roxadustat, 0.38 g/dL [0.27, 0.49]), while there were no clinically meaningful differences in the risk of MACE between the HIF-PHIs (all patients analysis [total n=12 320]: daprodustat vs. roxadustat, HR 0.89 [0.73, 1.08]; daprodustat vs. vadadustat, HR 0.99 [0.82, 1.21]; roxadustat vs. vadadustat, HR 1.12 [0.92, 1.37]). Results were similar in analyses of ESA non-users and prevalent dialysis patients. Conclusions In the setting of anaemia in CKD, indirect treatment comparisons suggest that daprodustat, roxadustat, and vadadustat are broadly clinically comparable in terms of efficacy and cardiovascular safety (precision was low for the latter), while daprodustat may be associated with reduction in fatigue to a greater extent than roxadustat.
Background Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are oral alternatives to current standard-of-care treatments for anaemia in chronic kidney disease (CKD). We conducted network meta-analyses to indirectly compare clinical outcomes for three HIF-PHIs in dialysis and non-dialysis populations with anaemia in CKD. Methods The evidence base comprised phase III, randomised, controlled trials evaluating daprodustat, roxadustat, or vadadustat. Three outcomes were evaluated: efficacy (change from baseline in haemoglobin [Hgb]), cardiovascular safety (time to first major adverse cardiovascular event [MACE]) and quality of life (change from baseline in 36-Item Short Form Health Survey [SF-36] Vitality score). Analyses were performed separately for all patients and for erythropoiesis-stimulating agent (ESA) non-users at baseline (non-dialysis population) or prevalent dialysis patients (dialysis population). Bayesian Markov Chain Monte Carlo methods with non-informative priors were used to estimate the posterior probability distribution and generate pairwise treatment comparisons. Point estimates (medians of posterior distributions) and 95% credible intervals (CrI) were calculated. Results Seventeen trials were included. In non-dialysis patients, there were no clinically meaningful differences between the three HIF-PHIs with respect to Hgb change from baseline (all patients analysis [total n=7907]: daprodustat vs. roxadustat, 0.09 g/dL [95% CrI -0.14, 0.31]; daprodustat vs. vadadustat, 0.09 g/dL [-0.04, 0.21]; roxadustat vs. vadadustat, 0.00 g/dL [-0.22, 0.22]) or risk of MACE (all patients analysis [total n=7959]: daprodustat vs. roxadustat, hazard ratio [HR] 1.16 [95% CrI 0.76, 1.77]; daprodustat vs. vadadustat, 0.88 [0.71, 1.09]; roxadustat vs. vadadustat, 0.76 [0.50, 1.16]). Daprodustat showed a greater increase in SF-36 Vitality compared with roxadustat (total n=4880; treatment difference 4.70 points [95% CrI 0.08, 9.31]). In dialysis patients, Hgb change from baseline was higher with daprodustat and roxadustat compared with vadadustat (all patients analysis [total n=11 124]: daprodustat, 0.34 g/dL [0.22, 0.45]; roxadustat, 0.38 g/dL [0.27, 0.49]), while there were no clinically meaningful differences in the risk of MACE between the HIF-PHIs (all patients analysis [total n=12 320]: daprodustat vs. roxadustat, HR 0.89 [0.73, 1.08]; daprodustat vs. vadadustat, HR 0.99 [0.82, 1.21]; roxadustat vs. vadadustat, HR 1.12 [0.92, 1.37]). Results were similar in analyses of ESA non-users and prevalent dialysis patients. Conclusions In the setting of anaemia in CKD, indirect treatment comparisons suggest that daprodustat, roxadustat, and vadadustat are broadly clinically comparable in terms of efficacy and cardiovascular safety (precision was low for the latter), while daprodustat may be associated with reduction in fatigue to a greater extent than roxadustat.
The design of clinical protocols and the selection of drugs with appropriate posology are critical parameters for therapeutic outcomes. Optimal therapeutic protocols could ideally be designed in all diseases including for millions of patients affected by excess iron deposition (EID) toxicity based on personalised medicine parameters, as well as many variations and limitations. EID is an adverse prognostic factor for all diseases and especially for millions of chronically red-blood-cell-transfused patients. Differences in iron chelation therapy posology cause disappointing results in neurodegenerative diseases at low doses, but lifesaving outcomes in thalassemia major (TM) when using higher doses. In particular, the transformation of TM from a fatal to a chronic disease has been achieved using effective doses of oral deferiprone (L1), which improved compliance and cleared excess toxic iron from the heart associated with increased mortality in TM. Furthermore, effective L1 and L1/deferoxamine combination posology resulted in the complete elimination of EID and the maintenance of normal iron store levels in TM. The selection of effective chelation protocols has been monitored by MRI T2* diagnosis for EID levels in different organs. Millions of other iron-loaded patients with sickle cell anemia, myelodysplasia and haemopoietic stem cell transplantation, or non-iron-loaded categories with EID in different organs could also benefit from such chelation therapy advances. Drawbacks of chelation therapy include drug toxicity in some patients and also the wide use of suboptimal chelation protocols, resulting in ineffective therapies. Drug metabolic effects, and interactions with other metals, drugs and dietary molecules also affected iron chelation therapy. Drug selection and the identification of effective or optimal dose protocols are essential for positive therapeutic outcomes in the use of chelating drugs in TM and other iron-loaded and non-iron-loaded conditions, as well as general iron toxicity.
Acetylsalicylic acid or aspirin is the most commonly used drug in the world and is taken daily by millions of people. There is increasing evidence that chronic administration of low-dose aspirin of about 75–100 mg/day can cause iron deficiency anaemia (IDA) in the absence of major gastric bleeding; this is found in a large number of about 20% otherwise healthy elderly (>65 years) individuals. The mechanisms of the cause of IDA in this category of individuals are still largely unknown. Evidence is presented suggesting that a likely cause of IDA in this category of aspirin users is the chelation activity and increased excretion of iron caused by aspirin chelating metabolites (ACMs). It is estimated that 90% of oral aspirin is metabolized into about 70% of the ACMs salicyluric acid, salicylic acid, 2,5-dihydroxybenzoic acid, and 2,3-dihydroxybenzoic acid. All ACMs have a high affinity for binding iron and ability to mobilize iron from different iron pools, causing an overall net increase in iron excretion and altering iron balance. Interestingly, 2,3-dihydroxybenzoic acid has been previously tested in iron-loaded thalassaemia patients, leading to substantial increases in iron excretion. The daily administration of low-dose aspirin for long-term periods is likely to enhance the overall iron excretion in small increments each time due to the combined iron mobilization effect of the ACM. In particular, IDA is likely to occur mainly in populations such as elderly vegetarian adults with meals low in iron content. Furthermore, IDA may be exacerbated by the combinations of ACM with other dietary components, which can prevent iron absorption and enhance iron excretion. Overall, aspirin is acting as a chelating pro-drug similar to dexrazoxane, and the ACM as combination chelation therapy. Iron balance, pharmacological, and other studies on the interaction of iron and aspirin, as well as ACM, are likely to shed more light on the mechanism of IDA. Similar mechanisms of iron chelation through ACM may also be implicated in patient improvements observed in cancer, neurodegenerative, and other disease categories when treated long-term with daily aspirin. In particular, the role of aspirin and ACM in iron metabolism and free radical pathology includes ferroptosis, and may identify other missing links in the therapeutic effects of aspirin in many more diseases. It is suggested that aspirin is the first non-chelating drug described to cause IDA through its ACM metabolites. The therapeutic, pharmacological, toxicological and other implications of aspirin are incomplete without taking into consideration the iron binding and other effects of the ACM.
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