Pediatric Clinics of North America - CIPERJ

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Fig. 1. Guideline for initiating, modifying, and monitoring hydroxyurea therapy (see text for further details). Asterisk indicates prehydroxyurea laboratory studies that are performed to help determine the etiology of potential treatment related laboratory changes or toxicities (eg, transaminitis, macrocytosis, and reticulocytopenia).
494 HEENEY & WARE in the morning or before school or the workday but can be in the afternoon, early evening, or before bedtime. The exact timing should not be regimented or overly emphasized; the critical feature is reliable dosing once each day. Families may worry about ‘‘missing a dose’’ by several hours but this is not a problem; it should be emphasized, however, that the daily dose just needs to be swallowed at some time during each day. Occasional patients (approximately 5%) mention gastrointestinal symptoms, such as stomachache or nausea, after taking hydroxyurea in the morning; in these instances, changing to evening dosing almost always leads to resolution of symptoms. Dose escalation to maximum tolerated dose Beneficial effects of hydroxyurea can begin in the first few weeks after commencing therapy [71], which can lead to some reluctance by medical providers to increase the dose beyond that needed for subjective clinical improvement. Because the salutary laboratory effects of hydroxyurea, especially induction of HbF and diminution of WBC and absolute neutrophil count (ANC), are dose dependent [32,45], however, it seems logical and advisable to increase the daily hydroxyurea dose to achieve the MTD. Based on comparative data documenting superior laboratory effects when hydroxyurea is prescribed at MTD [45], the goal of hydroxyurea should be to achieve modest marrow suppression without undue hematologic toxicity. After initiating hydroxyurea therapy (approximately 20 mg/kg/d), the child is seen in the outpatient clinic setting approximately every 4 weeks. At each interval visit, medical history is obtained and physical examination performed along with a discussion of dosing issues and emphasis on daily adherence. A complete blood cell count with WBC differential and reticulocyte count should be performed at each interval visit, and the next month’s dose should not be ordered or dispensed until that day’s weight and blood counts are available. The daily dose should be increased by approximately 5 mg/kg/d every 8 weeks if no toxicity occurs. The 4-week interval is too short for most dose adjustments, because hematologic toxicity can accumulate and not manifest fully until 8 weeks after a dose increase. It is critical to examine the trends in peripheral blood counts at each visitdsometimes toxicity is slowly cumulative and can be anticipated based on changes identified over 8 to 16 weeks. Hydroxyurea is titrated most easily according to the peripheral blood counts and typically is limited by neutropenia, occasionally by reticulocytopenia, and more rarely by thrombocytopenia. The target ANC for MTD should be approximately 2 to 4 10 9 /L (2000–4000 per mL), although other hematologic toxicity may limit dose escalation. Based on published data [45,55,57], most children with HbSS require a dose of 25 to 30 mg/kg/d to reach this MTD. The maximum daily dose of hydroxyurea should not exceed 35 mg/kg/d or 2000 mg/d; failure to achieve marrow suppression at these doses strongly suggests medication nonadherence. The MTD,
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Pediatr Clin N Am 55 (2008) xiii-xi
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Pediatr Clin N Am 55 (2008) 287-304
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DECISION ANALYSIS IN PEDIATRIC HEMA
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Nietert et al [30] Treatment of sic
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VENOUS THROMBOEMBOLISM IN CHILDREN
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PEDIATRIC ARTERIAL ISCHEMIC STROKE
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CARE OF PATIENTS WITH VASCULAR ANOM
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358 RODRIGUEZ & HOOTS Fig. 1. X-lin
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Table 1 Clotting factor concentrate
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Table 1 (continued ) Factor VIII (o
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364 RODRIGUEZ & HOOTS was administe
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366 RODRIGUEZ & HOOTS Antifibrinoly
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368 RODRIGUEZ & HOOTS infections an
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370 RODRIGUEZ & HOOTS Fig. 3. Schem
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372 RODRIGUEZ & HOOTS protein is no
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374 RODRIGUEZ & HOOTS [2] Berntorp
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376 RODRIGUEZ & HOOTS [42] Carcao M
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378 ROBERTSON et al von Willebrand
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380 ROBERTSON et al Fig. 2. A propo
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382 ROBERTSON et al a heterogenous
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384 ROBERTSON et al of considering
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386 ROBERTSON et al Type 2M Type 2M
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388 ROBERTSON et al Desmopressin is
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390 ROBERTSON et al References [1]
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392 ROBERTSON et al [46] Nesbitt IM
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394 BLANCHETTE & BOLTON-MAGGS A key
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396 BLANCHETTE & BOLTON-MAGGS recep
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398 BLANCHETTE & BOLTON-MAGGS and p
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400 BLANCHETTE & BOLTON-MAGGS Fig.
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402 BLANCHETTE & BOLTON-MAGGS in di
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404 BLANCHETTE & BOLTON-MAGGS the s
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406 BLANCHETTE & BOLTON-MAGGS findi
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408 BLANCHETTE & BOLTON-MAGGS as a
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410 BLANCHETTE & BOLTON-MAGGS splen
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412 BLANCHETTE & BOLTON-MAGGS with
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414 BLANCHETTE & BOLTON-MAGGS react
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416 BLANCHETTE & BOLTON-MAGGS [16]
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422 FASANO & LUBAN of storage and t
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424 FASANO & LUBAN Leukocyte reduct
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426 FASANO & LUBAN RBCs is decrease
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Table 1 Blood component characteris
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430 FASANO & LUBAN Alloimmunization
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432 FASANO & LUBAN of individual un
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434 FASANO & LUBAN patients have an
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436 FASANO & LUBAN adults; therefor
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438 FASANO & LUBAN [21]. Meta-analy
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440 FASANO & LUBAN Pretransfusion m
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Page 164 and 165: THALASSEMIA UPDATE 449 hypochromia
Page 166 and 167: THALASSEMIA UPDATE 451 Fig. 1. Chan
Page 168 and 169: THALASSEMIA UPDATE 453 delivery of
Page 170 and 171: THALASSEMIA UPDATE 455 thromboses i
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Page 178 and 179: ORAL IRON CHELATORS 463 large iron-
Page 180 and 181: ORAL IRON CHELATORS 465 of 50 child
Page 182 and 183: ORAL IRON CHELATORS 467 Table 2 Com
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Page 200 and 201: HYDROXYUREA FOR CHILDREN WITH SICKL
Page 218 and 219: 504 TRACY & RICE congenital spheroc
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Page 228 and 229: 514 TRACY & RICE Table 1 Effect of
Page 230 and 231: 516 TRACY & RICE decreased bilirubi
Page 232 and 233: 518 TRACY & RICE [13] Bader-Meunier
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