Rabaa M. Al-Rousan

Iron-Induced Cardiac Damage: Role of Apoptosis and Deferasirox Intervention

Excess cardiac iron levels are associated with cardiac damage and can result in increased morbidity and mortality. Here, we hypothesize that elevations in tissue iron can activate caspase-dependent signaling, which leads to increased cardiac apoptosis and fibrosis, and that these alterations can be attenuated by iron chelation. Using an iron-overloaded gerbil model, we show that increased cardiac iron is associated with reduced activation of Akt (Ser473 and Thr308), diminished phosphorylation of the proapoptotic regulator Bad (Ser136), and an increased Bax/Bcl-2 ratio. These iron-overload-induced alterations in Akt/Bad phosphorylation and Bax/Bcl-2 ratio were coupled with increased activation of the downstream caspase-9 (40/38- and 17-kDa fragments) and apoptosis executioner caspase-3 (19- and 17-kDa fragments), which were accompanied by evidence of elevated cytoskeletal α-fodrin cleavage (150- and 120-kDa fragments), discontinuity of myocardial membrane dystrophin immunoreactivity, increases in the number of terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL)-positive cells (nucleic DNA fragmentation), and cardiac fibrosis. We demonstrate that the administration of deferasirox, a tridentate iron chelator, is associated with diminished tissue iron deposition, attenuated activation of caspases, reduced α-fodrin cleavage, improved membrane integrity, decreased TUNEL reactivity, and attenuated cardiac fibrosis. These results suggest that the activation of caspase-dependent signaling may play a role in the development of iron-induced cardiac apoptosis and fibrosis, and deferasirox, via a reduction in cardiac tissue iron levels, may be useful for decreasing the extent of iron-induced cardiac damage.

Deferasirox removes cardiac iron and attenuates oxidative stress in the iron-overloaded gerbil

Iron‐induced cardiovascular disease is the leading cause of death in iron‐overloaded patients. Deferasirox is a novel, once daily oral iron chelator that was recently approved for the treatment of transfusional iron overload. Here, we investigate whether deferasirox is capable of removing cardiac iron and improving iron‐induced pathogenesis of the heart using the iron overload gerbil model. Animals were randomly divided into three groups: control, iron overload, and iron overload + deferasirox treatment. Iron‐dextran was given 100 mg/kg per 5 days i.p for 10 weeks. Deferasirox treatment was taken post iron loading and was given at 100 mg/kg/day p.o for 1 or 3 months. Cardiac iron concentration was determined by inductively coupled plasma atomic emission spectroscopy. Compared with the untreated group, deferasirox treatment for 1 and 3 months decreased cardiac iron concentration 17.1% (P = 0.159) and 23.5% (P < 0.05), respectively. These treatment‐associated reductions in cardiac iron were paralleled by decreases in tissue ferritin expression of 20% and 38% at 1 and 3 months, respectively (P < 0.05). Using oxyblot analysis and hydroethidine fluorescence, we showed that deferasirox significantly reduces cardiac protein oxidation and superoxide abundance by 36 and 47.1%, respectively (P < 0.05). Iron‐induced increase in oxidative stress was also associated with increased phosphorylation of ERK‐, p38‐, and JNK‐mitogen‐activated protein kinase (MAPK). Interestingly, deferasirox treatment significantly diminished the phosphorylation of all three MAPK subfamilies. These results suggest that deferasirox may confer a cardioprotective effect against iron induced injury. Am. J. Hematol. 2009.

Deferasirox protects against iron-induced hepatic injury in Mongolian gerbil

Iron overload is associated with an increased risk of liver complications including fibrosis, cirrhosis, and hepatocellular carcinoma. Deferasirox is a new oral chelator with high iron-binding potency and selectivity. Here we investigate the ability of deferasirox to remove excessive hepatic iron and prevent iron-induced hepatic injury. Adult male Mongolian gerbils were divided into 3 groups (n=5/group)-control, iron overload (100 mg iron-dextran/kg body weight/5 days; intraperitoneal for 10 weeks), and iron overload followed by deferasirox treatment (100 mg deferasirox/kg body weight/d; pulse oral for 1 or 3 months). Compared with the nontreated iron overload group, deferasirox reduced hepatic iron concentration by 44% after 3 months of treatment (P<0.05). Histological analysis of hepatic tissue from the iron overloaded group detected frequent iron deposition, evidence of hepatic damage, and an accumulation of lipid vacuoles. Iron deposition was significantly diminished with deferasirox treatment, and no evidence of lipid accumulation was observed. Immunoblotting demonstrated that iron overload caused approximately 2-fold increase in hepatic ferritin expression (P<0.05), which was 48% lower after 3 months of deferasirox treatment (P<0.05). Deferasirox treatment also was associated with reduced hepatic protein oxidation, superoxide abundance, and cell death. The percentage of terminal deoxynucleotidyl transferase dUTP nick end labeling positive cells in the deferasirox-treated livers was 41% lower than that of iron overloaded group (P<0.05). Similarly, an iron-related increase in the expression of Bax/Bcl2, Bad, and caspase-3 were significantly lower after deferasirox treatment. These findings suggest that deferasirox may confer protection against iron-induced hepatic toxicity.

Pharmacy Education in the Palestinian Territories

We are delighted that the American Journal of Pharmaceutical Education has recently focused on pharmaceutical practice and pharmacy education in Arab countries as part of its International Pharmacy Education Supplement. In 2006, Al-Wazaify and colleagues published an article titled “Pharmacy Education in Jordan, Saudi Arabia, and Kuwait” followed by a 2009 article by Kheir and colleagues titled “Pharmacy Education and Practice in 13 Middle Eastern Countries.”1,2 The latter article not only shed a light on pharmaceutical education in Arab countries, which are underrepresented in international literature, but it also started a constructive discussion forum in the American Journal of Pharmaceutical Education, including several letters.3-5 To further enrich this discussion, we present here a synopsis of pharmacy education in the Palestinian territories. It is fair to say that colleges and schools of pharmacy and, in general, pharmacy education in the Palestinian Territories (East Jerusalem, West Bank, and Gaza Strip) represent a unique case study. For many years, higher education in the Palestinian Territories was stalled due to the ongoing Israeli-Palestinian conflict. Up till 1992, there was not a single pharmacy school in the Palestinian Territories, and public and private-owned pharmacies relied on pharmacists educated abroad and registered in neighboring country associations, such as the Jordanian Pharmaceutical Association. The establishment of the Faculty of Pharmacy at Al-Azhar University in Gaza Strip (established in 1992) and the Department of Pharmacy at An-Najah University in West Bank (established in 1994) marked a significant progress in pharmacy education in the Palestinian Territories. Currently, there are 5 schools of pharmacy that offer bachelor and doctor of pharmacy (PharmD) degrees, and bachelor and master of pharmaceutical sciences degrees.6-10 Every year, more than 500 students are admitted to the bachelor of pharmacy programs at Al-Azhar, An-Najah, Hebron, and Al-Quds (in East Jerusalem) universities or PharmD programs at An-Najah and Birzeit universities. Admission is based solely on scores on the General Secondary School Examination (known as the Tawjihi) and little consideration is given to nonacademic criteria. Although these programs are accredited by the Palestinian Ministry of Higher Education, their curricula are focused on biomedical and pharmaceutical sciences and short in clinical, administrative, and experiential courses. Bachelor of pharmacy programs (5 years; 160-180 credit hours) consist of 73-81% biomedical and pharmaceutical sciences, roughly 13% pharmacy practice, less than10% social and administrative pharmacy and experiential education courses, and 720-1 440 hours of community pharmacy training.6-8 The PharmD programs include biomedical and pharmaceutical sciences (around 75%) and pharmacy practice and social and administrative pharmacy (around 25%) courses, more than 1 000 hours of community pharmacy training and an additional sixth year of pharmacy clerkships.7,9 Moreover, the faculty member to student ratio (1:40) is generally low compared with pharmacy schools in surrounding countries and the faculty body consists mainly of biomedical and pharmaceutical sciences faculty members (More than 70%).6-9 Thus, Palestinian Territories’ schools of pharmacy provide qualified pharmacists to meet the needs of the public and private pharmacies; however, there is a lack of clinical pharmacists with specialized residency trainings. This reflects the shortage in academic and research resources and the inability to attract qualified and well trained faculty members in the areas of pharmacy administration and pharmacy practice. This article has uncovered several areas where additional research could be valuable. While the scope of this investigation was confined to the schools of pharmacy in the Palestinian Territories, future studies can extend the present investigation to the Middle East countries and investigate the student pharmacist’s perceptions on the current pharmacy curriculum in the Palestinian Territories.