Treatments for thalassemias depend on the type and severity of the disorder. People who are carriers or who have alpha or beta thalassemia trait have mild or no symptoms. They’ll likely need little or no treatment. Show Doctors use three standard treatments for moderate and severe forms of thalassemia. These treatments include blood transfusions, iron chelation (ke-LAY-shun) therapy, and folic acid supplements. Other treatments have been developed or are being tested, but they're used much less often. Standard TreatmentsBlood TransfusionsTransfusions of red blood cells are the main treatment for people who have moderate or severe thalassemias. This treatment gives you healthy red blood cells with normal hemoglobin. During a blood transfusion, a needle is used to insert an intravenous (IV) line into one of your blood vessels. Through this line, you receive healthy blood. The procedure usually takes 1 to 4 hours. Red blood cells live only for about 120 days. So, you may need repeated transfusions to maintain a healthy supply of red blood cells. If you have hemoglobin H disease or beta thalassemia intermedia, you may need blood transfusions on occasion. For example, you may have transfusions when you have an infection or other illness, or when your anemia is severe enough to cause tiredness. If you have beta thalassemia major (Cooley's anemia), you’ll likely need regular blood transfusions (often every 2 to 4 weeks). These transfusions will help you maintain normal hemoglobin and red blood cell levels. Blood transfusions allow you to feel better, enjoy normal activities, and live into adulthood. This treatment is lifesaving, but it's expensive and carries a risk of transmitting infections and viruses (for example, hepatitis). However, the risk is very low in the United States because of careful blood screening. For more information, go to the Health Topics Blood Transfusion article. Iron Chelation TherapyThe hemoglobin in red blood cells is an iron-rich protein. Thus, regular blood transfusions can lead to a buildup of iron in the blood. This condition is called iron overload. It damages the liver, heart, and other parts of the body. To prevent this damage, doctors use iron chelation therapy to remove excess iron from the body. Two medicines are used for iron chelation therapy.
Folic Acid SupplementsFolic acid is a B vitamin that helps build healthy red blood cells. Your doctor may recommend folic acid supplements in addition to treatment with blood transfusions and/or iron chelation therapy. Other TreatmentsOther treatments for thalassemias have been developed or are being tested, but they're used much less often. Blood and Marrow Stem Cell TransplantA blood and marrow stem cell transplant replaces faulty stem cells with healthy ones from another person (a donor). Stem cells are the cells inside bone marrow that make red blood cells and other types of blood cells. A stem cell transplant is the only treatment that can cure thalassemia. But only a small number of people who have severe thalassemias are able to find a good donor match and have the risky procedure. For more information, go to the Health Topics Blood and Marrow Stem Cell Transplant article. Possible Future TreatmentsResearchers are working to find new treatments for thalassemias. For example, it might be possible someday to insert a normal hemoglobin gene into stem cells in bone marrow. This will allow people who have thalassemias to make their own healthy red blood cells and hemoglobin. Researchers also are studying ways to trigger a person's ability to make fetal hemoglobin after birth. This type of hemoglobin is found in fetuses and newborns. After birth, the body switches to making adult hemoglobin. Making more fetal hemoglobin might make up for the lack of healthy adult hemoglobin. Treating ComplicationsBetter treatments now allow people who have moderate and severe thalassemias to live longer. As a result, these people must cope with complications that occur over time. An important part of managing thalassemias is treating complications. Treatment might be needed for heart or liver diseases, infections, osteoporosis, and other health problems. Source: National Heart, Lung, and Blood Institute, National Institutes of Health. Beta ThalassemiaNORD gratefully acknowledges Herbert L. Muncie, Jr. MD, Professor of Family Medicine, Department of Family Medicine, Louisiana State University School of Medicine, for assistance in the preparation of this report. Synonyms of Beta Thalassemia
Subdivisions of Beta Thalassemia
General DiscussionSummary Beta thalassemia is an inherited blood disorder characterized by reduced levels of functional hemoglobin. Hemoglobin is found in red blood cells; it is the red, iron-rich, oxygen-carrying pigment of the blood. A main function of red blood cells is to deliver oxygen throughout the body. Beta thalassemia has three main forms – minor, intermedia and major, which indicate the severity of the disease. Individuals with beta thalassemia minor usually do not have any symptoms (asymptomatic) and individuals often are unaware that they have the condition. Some individuals do experience a very mild anemia. Individuals with beta thalassemia major have a severe expression of the disorder; they often require regular blood transfusions and lifelong, ongoing medical care. The symptoms of beta thalassemia intermedia are widely variable and severity falls in the broad range between the two extremes of the major and minor forms. The characteristic finding of beta thalassemia is anemia, which is caused because red blood cells are abnormally small (microcytic), are not produced at the normal amounts, and do not contain enough functional hemoglobin. Consequently, affected individuals do not receive enough oxygen-rich blood (microcytic anemia) throughout the body. Affected individuals may experience classic signs of anemia including fatigue, weakness, shortness of breath, dizziness or headaches. Severe anemia can cause serious, even life-threatening complications if left untreated. Affected individuals are treated by regular blood transfusions. Because of repeated blood transfusions individuals with beta thalassemia major and intermedia may develop excess levels of iron in the body (iron overload). Iron overload can cause a variety of symptoms affecting multiple systems of the body, but can be treated with medications. Beta thalassemia is caused by mutations in the hemoglobin beta (HBB) gene. Individuals with beta thalassemia minor have a mutation in one HBB gene, while individuals with the intermediate and major forms have mutations in both HBB genes. Introduction Thalassemia is a term for a group of disorders in which there is reduced levels of hemoglobin, decreased red blood cell production and anemia. There are two main forms – alpha thalassemia and beta thalassemia, each with various subtypes. Beta thalassemia minor, also known as beta thalassemia trait, is a common condition. Beta thalassemia major was first described in the medical literature in 1925 by an American physician – Thomas Cooley. Beta thalassemia major is also known as Cooley’s anemia. Today, the classic clinical picture of beta thalassemia major is primarily seen in countries with insufficient resources to provide affected individuals with treatment (e.g. regular transfusions and iron-lowering medications).
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 Signs & SymptomsThe symptoms and severity of beta thalassemia varies greatly from one person to another. Individuals with beta thalassemia minor do not develop symptoms of the disorder but may have a mild anemia. Many individuals with beta thalassemia minor go through life never knowing they carry an altered gene for the disorder. A beta thalassemia major diagnosis is usually made during the first two years of life and individuals require regular blood transfusions and lifelong medical care to survive. When the disorder develops later during life, a diagnosis of beta thalassemia intermedia is given; individuals may only require blood transfusions on rare, specific instances. BETA THALASSEMIA MAJOR Severe anemia develops and is associated with fatigue, weakness, shortness of breath, dizziness, headaches, and yellowing of the skin, mucous membranes and whites of the eyes (jaundice). Affected infants often fail to grow and gain weight as expected based upon age and gender (failure to thrive). Some infants become progressively pale (pallor). Feeding problems, diarrhea, irritability or fussiness, recurrent fevers, abnormal enlargement of the liver (hepatomegaly), and the abnormal enlargement of the spleen (splenomegaly) may also occur. Splenomegaly may cause abdominal enlargement or swelling. Splenomegaly may be associated with an overactive spleen (hypersplenism), a condition that can develops because too many blood cells build up and are destroyed within the spleen. Hypersplenism can contribute to anemia in individuals with beta thalassemia and cause low levels of white blood cells, increasing the risk of infection, and low levels of platelets, which can lead to prolonged bleeding. If untreated, additional complications can develop. Beta thalassemia major can cause the bone marrow, the spongy material within certain bones, to expand. Bone marrow is where most of the blood cells are produced in the body. The bone marrow expands because it is trying to compensate for chronic anemia. This abnormal expansion causes bones to become thinner, wider and brittle. Affected bones may grow abnormally (bone deformities), particularly the long bones of the arms and legs and certain bones of the face. When facial bones are affected it can result in distinctive facial features including an abnormally prominent forehead (frontal bossing), full cheek bones (prominent malar eminence), a depressed bridge of the nose, and overgrowth (hypertrophy) of the upper jaw (maxillae), exposing the upper teeth. The affected bones have an increased fracture risk, particularly the long bones of the arms and legs. Some individuals may develop ‘knock knees’ (genu valgum), a condition in which the legs bend inward so that when a person is standing the knees will touch even if the ankles and feet are not. Even when treated, complications may develop, specifically the buildup of iron in the body (iron overload). Iron overload results from the blood transfusions required to treat individuals with beta thalassemia major. In addition, affected individuals experience greater iron absorption from the gastrointestinal tract, which contributes to iron overload (although this primarily occurs in untreated individuals). Iron overload can cause tissue damage and impaired function of affected organs such as the heart, liver and endocrine glands. Iron overload can damage the heart causing abnormal heart rhythms, inflammation of the membrane (pericardium) that lines the heart (pericarditis), enlargement of the heart and disease of the heart muscle (dilated cardiomyopathy). Heart involvement can progress to life-threatening complications such as heart failure. Liver involvement can cause scarring and inflammation of the liver (cirrhosis) and high pressure of the main liver vein (portal hypertension). Endocrine gland involvement can cause insufficiency of certain glands such as the thyroid (hypothyroidism) and, in rare cases, diabetes mellitus. Iron overload can also be associated with growth retardation and the failure or delay of sexual maturation. Additional symptoms that may occur include masses that form because of blood cell production outside of the bone marrow (extramedullary hematopoiesis). These masses primarily form in the spleen, liver, lymph nodes, chest, and spine and can potentially cause compression of nearby structures and a variety of symptoms. Affected individuals may develop leg ulcers, an increased risk of developing blood clots within a vein (venous thrombosis) and decreased bone mineralization resulting in brittle bones that are prone to fracture (osteoporosis). BETA THALASSEMIA INTERMEDIA DOMINANT BETA THALASSEMIA CausesMost beta thalassemia cases are caused by a mutation in the HBB gene. In extremely rare cases, a loss of genetic material (deletion) that includes the HBB gene causes the disorder. Genes provide instructions for creating proteins that play a critical role in many body functions. When a gene mutation occurs, the protein product may be faulty, inefficient, or absent. Depending upon the functions of the particular protein, this can affect many organ systems of the body. Individuals with beta thalassemia minor have a mutation in one HBB gene and are carriers for the disorder. Individuals with beta thalassemia intermedia or major have mutations in both HBB genes. Normal hemoglobin is made up of specialized proteins called globins, specifically two alpha chains and two beta chain proteins attached to a central heme ring. The HBB gene creates (encodes) beta globin protein chains. A mutation in one HBB gene results in either reduced or no production of beta chains from that gene. Regardless, the second (unaffected) copy of the HBB gene functions normally and produces enough beta chain protein to avoid symptoms, although red blood cells are still abnormally small and mild anemia can still develop. A mutation in two HBB genes results in either significantly reduced levels of beta chains (beta thalassemia intermedia) or an almost complete lack of beta chains (beta thalassemia major). The reduction or lack of beta globin protein chains leads to an imbalance with the normally-produced alpha globin protein chains and, ultimately, the defective formation of red blood cells, a lack of functional hemoglobin, and the failure to deliver sufficient amounts of oxygen to the body. In individuals with dominant beta thalassemia, the mutated HBB gene creates (synthesizes) an extremely unstable type of hemoglobin. Affected individuals have ineffective red blood cell formation (erythropoiesis). Researchers believe that additional factors influence the severity of beta thalassemia major and intermedia including modifier genes. Modifier genes, unlike the gene that causes beta thalassemia, affect the clinical severity of the disorder. More research is necessary to discover the various modifier genes associated with beta thalassemia and their role in the development of the disorder. Beta thalassemia is inherited in an autosomal recessive pattern. Recessive genetic disorders occur when an individual inherits an abnormal gene from each parent. If an individual receives one normal gene and one abnormal gene for the disease, the person will be a carrier for the disease, but usually will not show symptoms. The risk for two carrier parents to both pass the abnormal gene and, therefore, have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier, like the parents, is 50% with each pregnancy. The chance for a child to receive normal genes from both parents is 25%. The risk is the same for males and females. Affected PopulationsBeta thalassemia is relatively rare in the United States, but is one of the most common autosomal recessive disorders in the world. The incidence of symptomatic cases is estimated to be approximately 1 in 100,000 individuals in the general population. The disorder is particularly prevalent in the Mediterranean, Middle East, Africa, central Asia, the Indian subcontinent, and the Far East. Individuals in other parts of the world whose families are from these regions carry a greater risk of having beta thalassemia. DiagnosisA diagnosis of beta thalassemia is based upon identification of characteristic symptoms, a clinical evaluation and a variety of specialized tests. With beta thalassemia major, initial symptoms often become apparent during the first two years of life and include failure to thrive, a swollen abdomen, and symptoms of anemia. Beta thalassemia intermedia may be suspected in individuals who present with similar (yet milder) symptoms, but at a later age. In the United States, in many states, infants are diagnosed with a hemoglobin disorder through newborn screening. Newborn screening is a public health program that tests newborn infants for a variety of disorders that are treatable, but not readily apparent at birth. Each state’s newborn screening program (and the specific disorders tested for) is different. Most states do not routinely test for thalassemia. Clinical Testing and
Workup With beta thalassemia, a CBC is done to measure the amount of hemoglobin and the number and the size and shape of red blood cells, which are fewer in number and smaller in size than in normal individuals. Red blood cells may also be pale in color (hypochromic) and of varying shapes. The distribution of hemoglobin in red blood cells in individuals with beta thalassemia is uneven, giving the cells a distinctive “bull’s eye” appearance when viewed under a microscope. A blood sample can be tested to measure the amount of iron in the blood, which is often elevated in individuals with beta thalassemia. Molecular genetic testing can confirm a beta thalassemia diagnosis. Molecular genetic testing can detect mutations in the HBB gene known to cause the disorder, but is available only as a diagnostic service at specialized laboratories. Molecular genetic testing is not necessary to make a diagnosis of beta thalassemia and is generally used to identify at-risk, asymptomatic relatives, to aid prenatal diagnosis, and to attempt to predict the progression or severity of the disease in specific cases. Prenatal diagnosis in pregnancies with an increased risk of beta thalassemia is possible by amniocentesis or chorionic villus sampling (CVS) if the specific gene mutation has been identified in a family member. During amniocentesis, a sample of fluid that surrounds the developing fetus is removed and analyzed, while CVS involves the removal of tissue samples from a portion of the placenta. Standard TherapiesTreatment Individuals with beta thalassemia major and intermedia will benefit from referral to a thalassemia treatment center. These specialized centers provide comprehensive care including the development of specific treatment plans, monitoring and follow up of affected individuals and state-of-the-art medical care. Treatment at a specialized center ensures that individuals and their family members will be cared for by a professional healthcare team (physicians, nurses, physical therapists, social workers and genetic counselors) experienced in the treatment of individuals with beta thalassemia. Genetic counseling is recommended for affected individuals and their families. Psychosocial support for the entire family is essential as well. Specific therapeutic procedures and interventions may vary, depending upon numerous factors such as the specific type of beta thalassemia; progression of the disease; presence or absence of certain symptoms; severity of the disease upon diagnosis; individual’s age and general health; and/or other issues. Decisions concerning the use of a particular drug regimen and/or other treatments should be made by physicians and other members of the health care team in consultation with the patient based upon the specifics of their case; a thorough discussion of the potential benefits and risks, including possible side effects and long-term effects; patient preference; and other appropriate factors. Individuals with beta thalassemia minor usually do not develop symptoms and do not require treatment. It is important that individuals with beta thalassemia minor be correctly diagnosed, however, to avoid unnecessary treatments for similarly appearing conditions such as iron deficiency anemia. Physicians may recommend folic acid supplementation in individuals with mild cases of anemia. Supplementation with folic acid, a B vitamin, boosts the production of red blood cells in certain individuals. Along with blood transfusions, folic acid and medications may be given to lower iron levels. Individuals with beta thalassemia major require regular blood transfusions. A blood transfusion is a common procedure in which affected individuals receive donated blood to restore the levels of healthy, functioning hemoglobin to their blood. During this procedure, donated blood is delivered to the body through a small, plastic tube inserted into a blood vessel (intravenously). The procedure may take anywhere from 1-4 hours. Individuals with beta thalassemia major require regular blood transfusions as frequently as every 2-4 weeks in severe cases. Individuals with beta thalassemia intermedia occasionally require blood transfusions such as when suffering from an illness or infection or when planning to undergo surgery. In 2019, the U.S. Food and Drug Administration (FDA) approved luspatercept-aamt (Reblozyl) for the treatment of anemia in adult patients with beta thalassemia who require regular red blood cell transfusions. In 2022, betibeglogene autotemcel (Zynteglo) was approved by the FDA as the first cell-based therapy for adults and children with beta thalassemia who require regular blood transfusions. This is a one-time gene therapy treatment that is customized for each patient by genetically modifying their bone marrow stem cells to produce beta globin. Some individuals may be treated by the surgical removal of the spleen (splenectomy). An abnormally enlarged spleen (splenomegaly) can cause severe pain and contribute to anemia. An enlarged spleen in individuals with beta thalassemia may occur due to increased destruction of red blood cells, the formation of blood cells outside of the bone marrow (extramedullary hematopoiesis), repeated blood transfusions or iron overload. If other forms of therapy fail, removal of the spleen may be considered. Splenectomy has led to improvement in certain symptoms associated with beta thalassemia. However, this surgical procedure carries risks, which are weighed against benefits in each individual case. If a splenectomy is required, one month before the surgery pneumococcal conjugate vaccine should be given. In addition, antibiotic prophylaxis, usually penicillin 250 mg twice a day, is given the first two years after surgery and for children younger than 16 years. Because of advances in the treatment of beta thalassemia in the past several years, splenectomy is rarely necessary as a treatment for affected individuals. Individuals with beta thalassemia major and intermedia may develop iron overload, which occurs because of two reasons. First, blood transfusions cause the accumulation of excess iron in the body. Second, beta thalassemia can cause increased absorption of dietary iron by the gastrointestinal tract. The body has no normal way to remove excess iron. In individuals who receive regular blood transfusions, iron overload primarily occurs because of treatment. Iron overload causes a variety of symptoms affecting various body organ systems. Iron overload is treated by medications called iron chelators that bind to iron in the body allowing it to be dissolved in water and excreted from the body through the kidneys. Iron chelators used to remove excess iron include deferoxamine (Desferal), deferiprone (Ferriprox) and deferasirox (Exjade). Treatment of additional complications of beta thalassemia or iron overload is symptomatic and supportive. Special attention is recommended for the early diagnosis and prompt treatment of heart disease potentially associated with iron overload. Hearat disease is the main life-threatening complication in individuals with beta thalassemia. Investigational TherapiesSome affected individuals may be candidates for a hematopoietic stem cell transplantation, which can potentially cure the disorder. However, because of the risk of morbidity and mortality, it is reserved for individuals with serious complications who have not responded to other therapies. Hematopoietic stem cells are special cells found in bone marrow that manufacture different types of blood cells (e.g., red blood cells, platelets). Individuals with beta thalassemia are treated with allogeneic stem cell transplantation. During this type of transplant, an affected individual’s bone marrow cells are eradicated by chemotherapy or radiation and replaced with healthy marrow from a donor, usually from a closely matched family member. However, only about 20% of affected individuals will have a fully compatible family member or unrelated donor. A hematopoietic stem cell transplant has the potential to correct the underlying abnormality that causes beta thalassemia. Ideally, a hematopoietic stem cell transplant should be done before the age of 16 and before the onset of hepatomegaly, portal fibrosis or iron overload. Other gene therapy clinical trials are underway for individuals with beta thalassemia major. In gene therapy, the patient’s defective gene is replaced with a normal gene to enable the production of functional beta globin and prevent the development and progression of the disease. This therapy can, theoretically, lead to a “cure.” Certain drugs such as 5-azacytidine, decytabine and butyrate derivatives are being studied as potential treatments for individuals with beta thalassemia. These drugs induce the creation (synthesis) of fetal hemoglobin, which is produced in the developing fetus and newborn infants (before the body begins to produce adult hemoglobin). These drugs bind with the excess alpha protein chains thereby reducing the imbalance between alpha protein chains and beta protein chains. More research is necessary to determine the long-term safety and effectiveness of these medications. Hydroxyurea is another drug that helps stimulate the production of fetal hemoglobin. This drug has been studied as a treatment for individuals with beta thalassemia intermedia to increase hemoglobin levels, reduce the size of extramedullary masses and improve leg ulcers. Further studies such as controlled, randomized clinical trials would be beneficial to determine what role, if any, hydroxyurea can play in the treatment of beta thalassemia. Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site. For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office: Toll-free:
(800) 411-1222 Some current clinical trials also are posted on the following page on the NORD website: For information about clinical trials sponsored by private sources, in the main, contact: For more information about clinical trials conducted
in Europe, contact: ResourcesPlease note that some of these organizations may provide information concerning certain conditions potentially associated with this disorder. Supporting Organizations
ReferencesTEXTBOOKS Lukens JN. Thalassemia Major. In: NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:419. Lukens JN. Thalassemia Major. In: NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:419. JOURNAL ARTICLES DeLoughery TG. Microcytic anemia. N Engl J Med. 2014;1324-1331. http://www.ncbi.nlm.nih.gov/pubmed/25271605 De Sanctis V, Soliman AT, Elsedfy H, et al. Osteoporosis in thalassemia major: an update and the I-CET 2013 recommendations for surveillance and treatment. Pediatr Endocrinol Rev. 2013;11:167-180. http://www.ncbi.nlm.nih.gov/pubmed/24575552 Martin A, Thompson AA. Thalassemias. Pediatr Clin North Am. 2013;60:1383-1391. http://www.ncbi.nlm.nih.gov/pubmed/24237977 Drakopoulou E, Papanikolaou E, Georgomanoli M, Anagnou NP. Towards more successful gene therapy clinical trials for β-thalassemia. Curr Mol Med. 2013;13:1314-1330. http://www.ncbi.nlm.nih.gov/pubmed/23865429 Musallam KM, Cappellini MD, Taher AT. Iron overload in β-thalassemia: an emerging concern. Curr Opin Hematol. 2013;20:187-192. http://www.ncbi.nlm.nih.gov/pubmed/23426199 Banan M. Hydroxyurea treatment in β-thalassemia patients: to respond or not to respond? Ann Hematol. 2013;92:289-299. http://www.ncbi.nlm.nih.gov/pubmed/23318979 Musallam KM, Taher AT, Cappellini MD, Sankaran VG. Clinical experience with fetal hemoglobin induction therapy in patients with β-thalassemia. Blood. 2013;121:2199-2212. http://www.ncbi.nlm.nih.gov/pubmed/23315167 Payen E, Leboulch P. Advances in stem cell transplantation and gene therapy in the β-hemoglobinopathies. Hematology Am Soc Hematol Educ Program. 2012;2012:276-283. http://www.ncbi.nlm.nih.gov/pubmed/23233592 Galanello R, Origa R. Beta-thalassemia. Orphanet J Rare Dis. 2010;5:11. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2893117/ Cao A, Galanello R. Beta-thalassemia. Genet Med. 2010;12:61-76. http://www.ncbi.nlm.nih.gov/pubmed/20098328 Muncie HL Jr., Campbell J. Alpha and beta thalassemia. Am Fam Physician. 2009;80:339-344. http://www.ncbi.nlm.nih.gov/pubmed/19678601 INTERNET National Heart, Lung, and Blood Institute. Thalassemias. July 3, 2012. Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/thalassemia/ Accessed Sept. 12, 2018. Years Published1986, 1987, 1990, 1992, 1993, 1994, 1995, 1997, 1999, 2000, 2015, 2018 The information in NORD’s Rare Disease Database is for educational purposes only and is not intended to replace the advice of a physician or other qualified medical professional. The content of the website and databases of the National Organization for Rare Disorders (NORD) is copyrighted and may not be reproduced, copied, downloaded or disseminated, in any way, for any commercial or public purpose, without prior written authorization and approval from NORD. Individuals may print one hard copy of an individual disease for personal use, provided that content is unmodified and includes NORD’s copyright. National Organization for Rare Disorders (NORD) |
Which action will the nurse include in the plan of care for a patient who has thalassemia major?
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