Effective treatment of gastrointestinal bleeding with thalidomide--Chances and limitations

Abstract

For more than 50 years bleeding from gastrointestinal angiodysplasias has been treated by hormonal therapy with estrogens and progesterons. After a randomized study finally demonstrated that hormones have no effect on bleeding events and transfusion requirements, therapy has switched to endoscopic coagulation. However, angiodysplasias tend to recur over months to years and endoscopy often has to be repeated for long time periods. Thalidomide, which caused severe deformities in newborn children in the 1960s, is now increasingly used after it was shown to suppress tumor necrosis factor alpha, inhibit angiogenesis and to be also effective for treatment of multiple myeloma. In 2011 thalidomide was proven to be highly effective for treatment of bleeding from gastrointestinal angiodysplasias in a randomized study. Further evidence by uncontrolled studies exists that thalidomide is also useful for treatment of bleeding in hereditary hemorrhagic telangiectasia. In spite of this data, endoscopic therapy remains the treatment of choice in many hospitals, as thalidomide is still notorious for its teratogenicity. However, patients with gastrointestinal bleeding related to angiodysplasias are generally at an age in which women have no child-bearing potential. Teratogenicity is therefore no issue for these elderly patients. Other side-effects of thalidomide like neurotoxicity may limit treatment options but can be monitored safely.

Keywords: Angiodysplasia; Angiogenesis; Bleeding; Gastrointestine; Thalidomide; Therapy; Vascular endothelial growth factor; Vascular malformation.

Figure 1

Angiodysplasia: Superficial cherry-red complex vascular tumor.

Figure 2

Wireless capsule endoscopy: Bleeding from a small angiodysplasia in the small bowel.

Figure 3

Gastric arteriovenous ectasia (watermelon stomach): Multiple superficial ecstatic vascular complexes in the gastric antrum.