Thalidomide for refractory gastrointestinal bleeding from vascular malformations in patients with significant comorbidities

Abstract

Background: Refractory gastrointestinal bleeding (GIB) secondary to gastrointestinal vascular malformations (GIVM) such as gastrointestinal angiodysplasia (GIAD) and gastric antral vascular ectasia (GAVE) remains challenging to treat when endoscopic therapy fails. Recently thalidomide has been suggested as a treatment option for refractory GIB.

Aim: To determine the outcome of patients treated with thalidomide for refractory GIB due to GIVM.

Methods: IRB approved, single center, retrospective review of electronic medical records from January 2012 to November 2018. Patients age > 18 years old, who had > 3 episodes of GIB refractory to medical or endoscopic therapy, and who had been treated with thalidomide for at least 3 mo were included. The primary endpoint was recurrence of GIB 6 mo after initiation of thalidomide.

Results: Fifteen patients were included in the study, all with significant cardiac, hepatic, or renal comorbidities. The cause of GIB was GIAD in 10 patients and GAVE in 5 patients. Two patients were lost to follow up. Of the 13 patients followed, 38.5% (n = 5) had no recurrent GIB or transfusion requirement after treatment with thalidomide. Furthermore, 84.6% (n = 11) of patients had a reduction in transfusion requirements and hospitalizations for GIB. Thalidomide was discontinued in 2 patients due to cost (n = 1) and medication interaction (n = 1). Reported adverse reactions included fatigue (n = 3), neuropathy (n = 2), dizziness (n = 1), and constipation (n = 1). Six patients died during follow up due to unknown cause (n = 4) and sepsis (n = 2).

Conclusion: Thalidomide appears to be an effective treatment for refractory GIB due to GIAD or GAVE in a Western population with significant comorbidities.

Keywords: Angiodysplasia; Gastric antral vascular ectasia; Refractory gastrointestinal bleeding; Thalidomide; Vascular malformation.

Figure 1

Units of packed red blood cell transfused before and after initiation of thalidomide.

Figure 2

Endoscopic pictures of gastric antral vascular ectasia before and after treatment with thalidomide. A: Gastric antral vascular ectasia (GAVE) with visible bleeding prior to initiation of thalidomide; B: GAVE 3 mo after initiation of thalidomide; C: GAVE 8 mo after initiation of thalidomide.