Efficacy of Thalidomide for Recurrent Gastrointestinal Bleeding due to angiodysplasias in a Hemodialysis Patient

Sir,

A 74-year-old female, on maintenance hemodialysis, presented to us with malena. An upper gastrointestinal (GI) endoscopy and a colonoscopy showed diffuse angiodysplasias involving the entire GI tract (GIT). The small intestine was revisualized with double-balloon enteroscopy. She required several session of argon coagulation and blood transfusion. In spite of the endoscopic and medical treatment, the GIT blood persisted.

We started thalidomide 100 mg/day after informed consent. By 4 months of therapy, the GI bleeding was controlled and the patient had been stable over the last 12 months during our follow-up.

GIT bleeding due to angiodysplastic lesions of the digestive tract is commonly seen among patients on hemodialysis and is responsible for significant morbidity and mortality.[1] Vascular endothelial growth factor (VEGF) is an angiogenic peptide that is secreted in response to hypoxia, stimulates proliferation of vascular endothelial cells, and increases vessel permeability.[2] GIT angiodysplasias are characterized by elevated serum levels of VEGF.[3] Thalidomide is shown to suppress VEGF and leads to a disruption in the pathogenesis behind these pathological vessels. A few studies[45] have shown that thalidomide is an effective and relatively safe therapy for preventing recurrent bleeding. The dose adjustment or reduction is not necessary in patients with chronic kidney disease or in hemodialyzed patients.[5] Thalidomide does not have to be given for an indefinite period, low-dose therapy (100 mg) may be given for 4 months, and bleeding did not recur for many months after cessation of thalidomide.[3] The main side effects attributable to thalidomide are fatigue, constipation, and peripheral neuropathy, all problems that can exist in many dialyzed patients.[5] Fatigue can be partially ameliorated by given the drug at night, and in constipation, laxatives should be added whenever needed. Peripheral neuropathy should be looked for at all phases of therapy and especially after high cumulative doses of thalidomide have been given.

This case illustrates the possible use of thalidomide as a viable therapeutic option in hemodialyzed patients to control GIT bleeding from angiodysplasias.