MINUTES OF THE SEVENTY-NINTH MEETING
OF THE SICKLE CELL DISEASE ADVISORY COMMITTEE
COMMITTEE MEMBERS PRESENT
Barabino, Dr. Oswaldo Castro, J. Hoxie Jones-Carranza, Dr. Peter Lane,
Dr. Herbert Meiselman, Ms. Sonya Ross, Dr. Jeanne Smith, Dr. Marie
Stuart, Dr. Paul Swerdlow, Dr. Joseph Telfair, Dr. Tim Townes.
COMMITTEE MEMBERS ABSENT
EX-OFFICIO MEMBERS PRESENT
Ms. Barbara Adam
for Dr. William Hannon, Dr. Joseph DeSimone, Dr. Marie Mann, Dr. Robert
Sheffler, Dr. Martin Steinberg
EX-OFFICIO MEMBERS ABSENT
PROGRAM STAFF AND AFFILIATED ORGANIZATION
Mrs. Michelle Allen, Mr. Larry Allen, Dr. Barbara
Alving, DBDR; Dr. Duane Bonds, DBDR/SCDSRG; Dr. Carlo Brugnara,
Childrenss Hospital, Boston; Ms. Kristi Cooper, NHLBI; Dr. Gregory
Evans, DBDR/SCDSRG; Dr. Rebecca Haley, American Red Cross; Dr. Liana
Harvath, DBDR/BRP; Dr. Paul R. McCurdy; Dr. Helena Mishoe DBDR/BDP;
Dr. Charles Peterson, DBDR/BDP; Ms. Betsy Poindexter, FDA; Ms. Susan Pucie
DBDR, Dr. Martin Ruta, FDA, Dr. John Thomas DBDR/BDP, Dr. Virginia
Wanamaker, DHHS; Dr. Ellen Werner, DBDR/BDP; Dr. William P. Winter, Howard
Executive Secretary - Dr. Charles M. Peterson
Secretary - Ms. Petronella A. Barrow
I. Dr. Paul Swerdlow called the meeting to
order at 9:10 AM.
Dr. Charles Peterson read the required notification
regarding conflicts of interest and reminded those present to sign in on
the required sign-in sheets.
II. The Minutes of November 13, 2000 were
reviewed and approved.
III. Dr. Swerdlow introduced the
A. Dr. Martin Steinberg reviewed
Hemoglobin SC Disease.
He noted that approximately 1/800 African Americans
has the genotype but the clinical expression varies from extremely mild to
severe. In general, complications are about one half those seen in individuals
with Hb SS. He reviewed the data on the use of hydroxyurea in patients with Hb
SC. There are 3 phase I-II studies with patient numbers ranging from 5 - 8
subjects. There has been minimal toxicity reported to date in these trials all
of which used relatively low doses. There have been no studies of clinical
effectiveness or detailed studies of potential mechanisms of action of efficacy
in this population. Another problem is the lack of data regarding who with Hb
SC becomes ill and what predictors of clinical course may be valid in designing
a trial. The data regarding clinical severity may be present in the data base
for the Cooperative Study of Sickle Cell Disease but this has not been
B. Dr. Carlo Brugnara reviewed
Therapies to Prevent Dehydration of Sickle Erythrocytes. There are
a number of approaches being utilized to increase red cell hydration that
include the Gardos, Cl, and KCL cotransport channels. Clotrimazole has been
shown to block dehydration in cells, the SAD mouse and humans. The problem with
the drug in humans is that hepatic toxicity is found in persons with sickle
cell disease at doses above 20 -30 mg/kg/24 hours. Other compounds including Mg
pindolate, and compounds identified by industry (Icogen and NeuroSearch) are
being evaluated in preclinical and planned clinical trials. A combined
trial of magnesium and hydroxyurea is also being planned.
IV. Drs. Liana Harvath, Martin Ruta (FDA), and
Rebecca Haley (American Red Cross) presented the issue of leukoreduction
problems. On June 15, 2001, there will be a Blood Products Advisory Meeting
convened by the FDA to explore the problem of leukofiltration failures.
Leukoreduction has been advocated for all units of red cells in that this
procedure is associated with a decrease in alloimmunization and febrile
reactions in recipients. Approximately 1% of units are lost due to filtration
problems usually associated with clots in the unit. There has been some concern
that units from persons with sickle trait do not filter well. While a technical
solution to the problem is being sought, FDA has proposed screening of blood
donors for sickle cell trait.
The Committee felt that screening blood donors for
sickle hemoglobin would be counterproductive and deliver the wrong message to a
community where the shortage of donors presents tremendous problems. Dr. Jeanne
Smith volunteered to represent the Sickle Cell Advisory Committee opinion to
the FDA meeting on leukoreduction and report back to the Committee. Dr.
Swerdlow would also convene an ad hoc committee to draft a statement on behalf
of the Committee prior to the next meeting.
V. Dr. Swerdlow gave the Chairmans
report. He noted that there was a pending FDA Notice of Meeting on Anesthetic
and Life Support Drugs Advisory Committee. The meeting had been postponed from
its original time of June 14 and 15. The committee will discuss the medical use
of opiate analgesics in various patient populations including pediatric
patients and patients with chronic pain of nonmalignant etiology, as well as
the risk to benefit ratio of extending opiate treatment into these populations.
Dr. Swerdlow noted the importance of pain therapy for patients with sickle cell
disease and volunteered to attend the FDA meeting of the Anesthetic and Life
Support Drugs Advisory Committee and coordinate a response of the Sickle Cell
Disease Advisory Committee as necessary. He passed out the notice of meeting to
VI. Action Items from previous meeting
were completed or discussed as follows:
A. It was recommended by the committee
that the Sickle Cell Disease Research Group distribute a list of ongoing
clinical trials and brief progress reports on each as well as potential studies
and current priorities prior to the Committee Meeting. This was done by
B. Speakers for the next meeting should
be sought who could address the issues of clinical trials that increase
cellular hydration with magnesium and feasible clinical trials in SC disease.
This was accomplished.
C. The Protocol Review/DSMB Committees of
BABY HUG are requested to report to the Committee regarding development of the
protocol, age of participants, and considerations of therapeutic endpoints and
potential toxicities. Since DSMB deliberations are ongoing, this discussion was
postponed until the next meeting.
D. The issue of sickle cell trait as a
public health problem as well as a problem for the military will be
considered in future meetings. The committee will continue to try and see
if someone from the military can address the issue at a future meeting.
To date it has not been possible to get a person. Dr. Alving will contact the
Army Surgeon General to see if she can find someone to address the committee.
In response to these efforts, Lieutenant Colonel Robert Sheffler Consultant to
the Surgeon General for Hematology/Oncology and Chief of the Hematology
/Oncology Service at Brooke Army Medical Center will be attending the meetings.
He reported on the history of screening for sickle cell disease in the
military. After a great deal of activity in the 1960s and 1970s with the Kark
Report, changes in procedure were introduced such that there were no deaths in
the subsequent 10 years. In 1996 it was recommended that the army not screen.
Each service has its own policy. The Air Force screens and offers those found
positive the option to opt out of service. The Navy screens and identifies
those positive with a special neck tag and a red belt during heavy exercise
sessions. The marines screen but do not alter routine. The routine for marines
during training is to pay strict attention to protocol for hydration and
electrolyte restoration. The army had 8 deaths in the years 1999-2000 during
basic training. Of these, 5 were screened for presence of hemoglobin S and 3
were found positive. In view of the higher than expected prevalence, the Army
is reviewing its procedures with respect to screening.
The following motion was moved, seconded and
unanimously approved by the Committee.
Measures to prevent exertional heat illness eliminate
the disparity in sudden death during military basic training between persons
with sickle cell trait and persons without sickle cell trait and reduce the
risk of death in both groups. The Sickle Cell Disease Advisory Committee
1. All military services should systematically
implement measures to prevent exertional heat illness and monitor compliance
with such measures.
2. Routine screening of recruits for
sickle cell trait is unnecessary, potentially stigmatizing and discriminatory,
and should be discontinued.
3. Screening for sickle cell trait
may be appropriate prior to participation in selected activities that involve
predictable exposure to environmental hypoxia. In such circumstances, screening
should be universal and education and counseling should be provided to persons
identified as hemoglobinopathy carriers.
VII. Dr. Alving gave the Director's
Report from the Division of Blood Diseases and Resources.
progress on the book Management and Therapy of Sickle Cell Disease was reviewed
and the list of contents distributed. Each member of the Sickle Cell
Disease Advisory Committee was encouraged to review the entire book and forward
comments to Dr. Alving by June 28, 2001.
Dr. Alving distributed a number of letters that she
had received regarding a need for a network to perform clinical studies in
sickle cell research. She noted that within the current framework, the
goal of NHLBI is to develop a clinical research network through the sickle cell
centers. Plans for workshop on Adults with Sickle Cell Disease - to
be held in conjunction with HRSA. Received names of those who wished to
work in this area were planned.
VIII. Agency Reports
A. Department of the Army. Dr. Shefflers
report is summarized above (IV. D.)
B. Centers for Disease Control. Ms. Barbara
Adam gave the report. She had a number of questions regarding Hb SC
disease in response to a letter from a patient with the condition. Notable
among the issues raised include that few physicians or emergency rooms know of
the condition much less follow guidelines for care. Thus there appears to
be under reporting, miscoding, and misdiagnosis of the condition. There
are no studies known regarding quality of life issues for individuals with Hb
SC. The Committee concurred on the lack of data regarding quality of life
issues and encouraged development of a workshop in the area. It was
further pointed out that the ICD 9 codes for both SC disease and sickle beta
thalassemia make no sense and are confusing to health care providers. It
was noted that to change an ICD 9 code, one must work with the American Medical
Association. Dr. Swerdlow noted that he would coordinate an outreach for
the Committee to the AMA regarding the ICD 9 codes for SC disease and sickle
beta thalassemia disorders.
Ms. Adams noted the many changes occurring in the
methods of testing being used for neonatal screening. A number of gene
based kits are beginning to appear as are new methods using tandem, MALDI, and
ESI-mass spectroscopy for detecting hemoglobin variants. There is still
some interest on the part of the CDC in participating in or convening a
workshop on new methods. The Committee felt that such a conference might
attract international interest as well as interest from the many state
C. Health Resources and Services
Administration. Dr. Marie Mann reviewed the agencies appoaches to newborn
screening and the implications of new technologies for screening. There
has also been an increased interest in the ethical, legal and social issues
that accompany screening programs. Policies and procedures regarding the
use and storage of blood spot samples used for screening are under
evaluation. The agency would like to develop model procedures that could
D. Veterans Administration. Dr. Joseph DeSimone
noted that the VA is developing new funding opportunities for those that
historically treat minority populations. Details of these efforts will be
forwarded to the Committee as they appear.
IX. Update on Program Activities
TIME LINE FOR RECOMPETITION OF NHLBI COMPREHENSIVE
SICKLE CELL CENTERS (CSCCs)
A. Comprehensive Sickle Cell Centers Renewal.
Dr. Gregory Evans reviewed the time line for the renewal of the RFA for the
Sickle Cell Centers and noted that suggestions from the committee were taken to
incorporated in the new RFA.
Application Receipt: September
Merit Review: Spring 2002
Presentation of Proposed Funding Plan to NHLBI Advisory
Council: September 2002
B. Dr. Evans reported on a the Strategic
Plan for a Gene-Based Cure for Beta-Chain Hemoglobinopathies. The first 3
of 11 potential initiatives were presented to the Bureau of Extramural Advisors
(BEA) and the Council. These three initiatives dealt with approaches to
increasing hemoglobin F. One of the initiatives has been announced and
two others are moving forward.
C. MSH Patients Follow-up Cohort Trial.
Dr. Duane Bonds reviewed the status of trial and noted that an additional 5
years of follow-up was being planned by NHLBI. Dr. Steinberg mentioned that he
and others were working on a report updating the follow up of these patients.
D. BABY Hug Phase 3 Clinical Trial. This
protocol is under review by the DSMB at the present
E. Parvovirus B19 Study. Dr. Duane Bonds
announced that this cumulative incidence epidemiologic study has been initiated
through nine of the ten Sickle Cell Centers and recruitment of patients now
F. STOP 2 Trial. Dr. Bonds reported that the
trial was underway and 3 patients have been recruited.
G. Additional Clinical Trials in
Progress. Dr. Bonds reported that the Hip Core Trial continues to recruit
patients and now has 32 patients in follow up. This trial and a planned
trial in Acute Chest Syndrome are being coordinated through the Oakland Sickle
Cell Center. The Cooperative Study of Sickle Cell Disease Cohort Study
continues to encourage investigators to apply for ancillary funds to further
evaluate data. Interested investigators should contact Dr. Bonds.
H. A number of potential initiatives were
discussed. Dr. Bonds was encouraged to proceed with efforts in the
1. Sickle Cell Disease and the Lung.
Hydroxyurea and SC Disease.
3. Membrane active agents and Hb SC and
I. The Committee was reminded that the Sickle
Cell Disease Meetings at NHLBI will be from August 24-27, 2001
X. Dates of Next Meetings
November 5, 2001
June 3, 2002
XI. Summary List of Action Items
A. Dr. Jeanne Smith volunteered to represent
the Sickle Cell Advisory Committee to the FDA meeting on leukoreduction and
report back to the Committee. Dr. Swerdlow would also convene an ad hoc
committee to draft a statement on behalf of the Committee prior to the next
B. Dr. Swerdlow noted the importance of pain
therapy for patients with sickle cell disease and volunteered to attend the FDA
meeting of the Anesthetic and Life Support Drugs Advisory Committee and
coordinate a response of the Sickle Cell Disease Advisory Committee as
C. The Protocol Review/DSMB Committees of BABY
HUG are requested to report to the Committee regarding development of the
protocol, age of participants, and considerations of therapeutic endpoints and
D. The Committee concurred on the lack of data
regarding quality of life issues and health services utilization and encouraged
development of a workshop in the area.
E. Dr. Swerdlow noted that he would coordinate
an outreach for the Committee to the AMA regarding the ICD 9 codes for SC
disease and sickle beta thalassemia disorders.
F. Dr. Joseph DeSimone noted that the VA is
developing new funding opportunities for those that historically treat minority
populations. Details of these efforts will be forwarded to the Committee
as they appear.
G. Dr. Bonds was encouraged to proceed with
efforts in the following areas:
1. Sickle Cell Disease and the Lung.
2. Hydroxyurea and SC Disease.
3. Membrane active agents
and Hb SC and SS.
Sickle Cell Disease Advisory Committee
Charles M. Peterson,
Sickle Cell Disease Advisory Committee