The Journal of PED I ATR I CS 5 6 3
`
`Dejeroxamine and
`diethylenetriaminepentaacetic acid (DTP A)
`in tbalassemia
`
`Deferoxamine ( Desferal) and diethylenetriaminepentaacetic acid (DTPA) were used
`in 4 children with thalassemia major and increased the urinary excretion of iron
`in all of them. The best results were obtained in the children with the greatest iron
`overload. Therapy was less successful in a baby who had not yet accumulated
`much iron. This form of treatment is thought to be worthwhile as there is, at
`present, no other practical means of increasing iron output in thalassemic patie11ts.
`
`Robert McDonald, M.A., M.D. (Oxford), D.C.H:*
`
`CAPE TOWN, SOUTH AFRICA
`
`T H A L A s s E M I c children who live with(cid:173)
`in reach of a hospital should not die of
`anemia or infection, but they may die from
`iron overload, a consequence of the many
`blood
`transfusions which their hemolytic
`anemia necessitates. Iron accumulates in
`various parts of the body, including the
`heart, where heavy deposition in the myo(cid:173)
`cardium may ultimately result in cardiac
`failure. Autopsy studies on such patients
`have shown large amounts of iron-contain(cid:173)
`ing granules in the myocardium, as well as
`fibrosis and destruction of cardiac muscle. 1
`As only small amounts of iron are normally
`excreted from the body, any increased elim(cid:173)
`ination should benefit thalassemic children.
`While venesection is the quickest way of
`ridding the body of excess iron, this is not
`
`From the Department of Child Health,
`University of Cape ·Town and Groote Schuur
`Hospital.
`" Address, Department of Child H ea/th,
`Medical School, Obs•rvalory, .Cape Town, South Africa.
`
`thalassemia or
`in patients with
`possible
`other hemolytic anemias. The only other
`method available is the use of preparations
`which bind iron in the body in an excret(cid:173)
`able form. Two effective iron chelating
`agents are deferoxamine (Desferal·*) and
`die thy lenetriaminepen taacetic
`acid
`(DTPAt). We have had the opportunity of
`administering each of these preparations to
`4 children with thalassemia major and the
`purpose of this article is to report the re(cid:173)
`sults obtained.
`
`T H E P AT IEN T S
`
`Case 1. This boy, E. I., has been known to us
`since he was 8 years old. His parents and only
`brother are well; his sister is the second patient
`in this group. He presented in 1957 with symp·
`toms of anemia, an increase in fetal hemoglobin
`and a decrease in the osmotic fragility of the
`red cells. His parents had hematologic evidence
`of the thalassemic trait, and a diagnosis of thal·
`
`*Supplied by Ciba Pharioaccutical Company.
`tSupplied by Geigy Pharmaceuticals.
`
`
`1 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`

`

`5 6 4 McDonald
`
`October 1966
`
`assemia major was made in the child. Blood
`transfusions were given as required and when
`the intervals between these had shortened to '~
`weeks in 1960, his spleen was removed. Since
`then he has needed blood every 8 weeks. When
`chelation was commenced in 1964 it was esti(cid:173)
`mated that the boy had received about 16 Gm.
`of iron by blood transfusions. At this time his
`liver and heart were both appreciably enlarged.
`The hemoglobin was 4.3 Gm. per 100 ml. and
`the peripheral blood smear contained many
`nucleated red cells. The bone marrow showed
`erythroid hyperplasia. Serum iron was 220 µ,g
`per 100 ml. with 79.7 per cent saturation. De(cid:173)
`tails of treatment arc given below.
`Case 2. R. I., the sister of the first patient,
`was seen with her brother in 1957. Her illness
`has followed a similar course and as her signs
`are very much like the boy's they will not be
`described. By April, 1964, she had received
`about 15 Gm. iron by blood transfusion and
`chelation therapy was commenced at that time.
`Case 3. A. J., a 6-ycar-old boy, had been pale
`since the age of 4 months. When first seen by
`us at 9 months of age, his hemoglobin was 7
`Gm. per 100 ml., the liver and spleen were both
`enlarged, and a systolic cardiac murmur was
`heard. His red cell survival time was consider(cid:173)
`ably shortened with a half-life of only 15 days.
`Despite splenectomy at 15 months, blood trans(cid:173)
`fusion was necessary every 6 to 8 weeks. In 1964,
`when he was 7 years of age, his fetal hemoglobin
`was 5.3 per cent and there was some decrease
`in osmotic fragility of the red cells. He had re(cid:173)
`ceived about 8 Gm. iron from the blood trans(cid:173)
`fusions by this time. Deferoxamine was com(cid:173)
`menced in 1964 and DTPA was given 4 times
`during 1965. Details of therapy follow later.
`Case 4. G. D. is the youngest patient and was
`born in March, 1964. He was found to be anemic
`at 4 months of age, and, in our hospital, at 6
`months of age his hemoglobin was 6 Gm. per
`100 ml.; the fetal hemoglobin was 21.8 per cent
`and hemoglobin A2 , 3.5 per cent of the total.
`Both parents have
`the thalassemic trait. By
`August, 1965, the baby's intake of iron from
`blood transfusions was about 1 Gm. During his
`more recent hospital admissions he has been
`given deferoxamine and DTPA; the effects of
`these are shown later.
`
`MA TERIAL AND METH ODS
`
`Deferoxaminc has a strong affinity for
`trivalent iron with which it combines to
`
`low
`form ferrioxamine. The latter has a
`molecular weight and is rapidly excreted
`in the urine. Wohler,2 using Fe~9-labeled
`ferrioxamine found that most of it was elim(cid:173)
`inated within 24 hours. Deferoxamine may
`be lifesaving in acute iron poisoning,3·6 but
`it has also been found useful in chronic iron
`retention. 7- 9 The trisodium calcium complex
`of diethyelenetriam i nepentaacetic acid
`(DTPA) has also been found of value in
`chronic iron overload states.1 o-i3 It has been
`suggested that calcium is exchanged for iron
`at storage sites and that the newly formed
`chelate is then excreted in the urine.10 La(cid:173)
`beling with C 14 indicated that up to 70 per
`cent is eliminated from the body within 4
`hours and practically all of it is removed by
`24 hours.11
`Neither preparation is effectively absorbed
`when given by mouth, so that parenteral ad(cid:173)
`ministration is necessary. Deferoxamine is
`usually given
`intramuscularly and only
`chelates iron. In moderate doses it appears
`to be nontoxic. There was a report15 of
`ataxia, paralysis, and respiratory failure in
`experimental animals, but they had received
`excessively large doses of deferoxamine.
`As the maximum dose had not been estab(cid:173)
`lished, deferoxamine was administered in an
`initial daily dose of 1 Gm. (2 ml.) and in(cid:173)
`creased up to 3 Gm. ( 2 m l. three times a
`day). We wished to find out if increasing
`the dose of deferoxamine would result in a
`proportionately increased excreti~n of iron
`in the urine. Initial increases were not main(cid:173)
`tained, so the daily dose was i;educed to see
`if a steady output of iron was obtained on
`a 1 Gm. (2 ml.) dose, this being the dose
`selected as the most convenient one for out(cid:173)
`patient use.
`DTPA was given intravenously at the time
`of blood transfusion, either in the blood it(cid:173)
`self or in 5 per cent dextrose solution. Dos(cid:173)
`age varied from 125 to 200 mg. per kilo(cid:173)
`gram and was administered in a dilution
`of 1 Gm. in 150 ml. diluting fluid, given
`rather slowly. Intramuscular injection of
`DTPA is too painful for repeated use. Mag(cid:173)
`nesium as well as iron is eliminated by this
`agent,11 and as the serum-magnesium level
`
`
`2 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`

`

`Volume 69 Number 4
`
`Def er ox amine and DTP A tn thalassemia 5 6 5
`
`tends to be reduced in thalassemia/ 6 DTPA
`should probably not be used too frequently.
`No toxic effects were . apparent in our pa(cid:173)
`tients and serum magnesium, as well as cal(cid:173)
`cium levels, were substantially the same be(cid:173)
`fore and after chelation on the one occasion
`when these were measured.
`The determination of serum iron and la(cid:173)
`tent iron-binding capacity was carried out
`under controlled conditions of pH using un(cid:173)
`buffered sulfonated bathophenanthro!ine for
`color development. Urinary iron was deter(cid:173)
`mined by releasing iron from deferoxamine
`under controlled pH conditions using so(cid:173)
`dium hydrosulfite as a
`reducing agent.
`Thereafter two independent methods were
`used, employing either dipyridyl or unbuf(cid:173)
`fered bathophenanthroline for color develop(cid:173)
`ment.17
`
`RE SU LTS
`
`Figs. 1 to 7 show urinary iron excretion
`after chelation in the 4 patients. Their pre(cid:173)
`treatment figures for 24 hours were 0.32
`mg., 0.44 mg., 0.15 mg., and 0.25 mg., re(cid:173)
`spectively.
`
`The 2 children with the heaviest iron
`overload had a good response to deferoxa(cid:173)
`roine during three hospital admissions. The
`amount given was reduced to 1 Gm. ( 2 ml.)
`daily during their second and on their third
`admissions, in order to find out if there was
`a constant urinary excretion of iron per
`gram of Desferal. This amount was then
`given as outpatient treatment to the children
`on 4 days per week for the next 5 months.
`Values for urinary iron are not available
`during the latter period except for 2 periods
`of 24 hours each when the children were
`brought into the hospital for random 24
`hour urinary iron determinations. From the
`various values obtained it seemed that 10
`mg. iron per gram of Desferal was a con(cid:173)
`servative estimate of urinary iron excretion
`for each child. Although
`it cannot be
`claimed that this is an accurate value, it is
`thought it is not too far out as a basis for
`calculation. After 5 months the estimated
`output of iron in each child was 900 mg. In
`the case of the boy, his urinary iron output
`in the hospital was 630 mg., making a total
`excretion of iron of 1,500 mg. in 8 months.
`
`E.1. ~ IS ycon
`
`Iran
`Scru"'
`f9fi00Mf
`
`220
`
`SoturotiOft 0
`
`/ •
`
`?9.7
`
`60
`
`206
`
`80.6
`
`252
`
`248
`
`223
`
`232
`
`233
`
`266
`
`94.S
`
`68.2
`
`92.S
`
`74 .7 93.2
`
`93.0
`
`I
`
`. 2 3 4 S 6
`
`Fig. 1. Iron excretion with deferoxamine. (E. I ., 15 years.) Inverted arrows indicate serum
`iron determinations.
`
`
`3 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`

`

`5 G 6 McDonald
`
`October 1966
`
`A.I. t 12 ycors
`Sena• lton 260
`... 9/IOOMI
`$oturotloft... 96
`
`z
`0
`!
`
`250
`
`89
`
`298
`
`99
`
`2IO
`
`,JOI
`
`57
`
`90
`
`312
`
`93.6
`
`,.. . er • z
`
`ii
`:>
`
`IO
`
`"'
`
`Fig. 2. Iron excretion with deferoxaminc. (R. I., 12 years.) Inverted arrows indicate serum
`iron dclerminat:ions.
`
`A.J .
`
`,
`
`6 :r:car1 .
`
`Scru11
`Iron
`!'9/ 100 .,
`Soturotlon Ofo
`
`165
`88
`
`l«l
`9"'
`
`~~--"-'-..------'-~---it--~7---~1~1\-0 ~~~-1~5 ~~.11 l
`
`192
`
`155
`
`121
`
`Blood
`
`600111
`
`370•1
`
`600 • 1
`
`1~0 •1~
`12 3,56 7 119!0 1112~
`
`...,..,.bcr I Occc11bcr 196"'
`
`Scpgiobcr 1965
`
`so
`
`z
`~
`Q .
`'S
`"'°
`z
`.. .c 30
`... i
`v ..
`..
`er
`...
`JC
`~ 20
`1i • r
`
`z
`ii
`:>
`
`10
`
`A119U•I 196"'
`
`3 •onlh•
`ct ho••·
`
`Doy
`
`~
`
`3
`
`~
`er I 2
`
`Fig. 3. Iron excretion with deferoxaminc. (A. J., 6 years.) Inverted arrows in this and sub(cid:173)
`sequent Figs. indicate blood transfusions.
`
`111 I
`
`II 'II'
`
`
`4 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`

`

`Volume 69 Number 4
`
`Def eroxamine and DTPA m thalassemia 5 6 7
`
`E . 1. cl
`
`16 years
`
`Sc runt
`Iron
`}'g / 100 1111
`
`Soturotion °/o
`
`220 214
`
`100 100
`
`Sl3
`
`407
`
`93
`
`100
`
`Blood
`
`125
`
`..
`..
`"
`..
`"'
`....
`.!: so
`> ct "'
`
`:z
`0
`'!
`0
`:z
`...
`Q
`w
`IX
`u
`)(
`w
`
`<
`2
`I[
`:>
`
`100
`
`75
`
`25
`
`0
`
`E
`
`J96S
`
`..
`
`.,.
`
`3
`2
`
`.;.
`(l;
`>-'
`cS
`
`2
`April
`
`s 6 7
`May
`
`A + 8 9ivcn In Outrosc/Watcr
`
`Fig. 4. Iron excretion with intravenous DTPA. (E. I., 16 years.)
`
`R.I.
`
`j
`
`13 y'ors.
`
`Scru"' Iron
`pg I 100 1111
`
`Sa tura tlon °/o
`
`280 300
`
`92 100
`
`411
`
`89
`
`Blood
`
`1200 .. 1
`
`1200 .. 1
`
`:z
`~
`
`?;
`2
`0
`...
`;:
`ct
`u
`)(
`w
`> I[
`<
`2
`ii
`:>
`
`<
`Q:
`>-'
`d
`
`100
`
`..
`..
`"
`..
`0
`""' 7S
`....
`
`50
`
`2S
`
`.!:
`"'
`
`E
`
`1965
`
`..
`
`3
`
`2
`
`.,.
`
`2
`Apr II
`
`s 6 7
`May
`
`A+ 8 give n In Ocxtroac/Watc r
`
`A
`Fig. 5. I ron excretion with intravenous DTPA. (R. I., 13 years.)
`
`
`5 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`

`

`5 6 8 McDonald
`
`October 1966
`
`A.J. c! 6 :r:eo;s.
`
`Scrum
`I ron
`µ9/ •00 ml·
`
`Soturotion °/o
`
`109
`
`81
`
`167
`
`78
`
`225
`
`Blood
`38
`
`980ml
`
`1200ml
`
`600 ml ~ 600ml 600 ml ~ 900ftll
`
`-0
`
`30
`
`20
`
`10
`
`0
`
`..
`"
`"'
`...
`...
`.:
`"'
`
`E
`
`1965
`
`9
`Morch
`
`13 14
`Moy
`
`7
`July
`
`IQ
`Sc:ptunbc: r
`
`4
`
`2
`
`z
`l?
`0
`z
`...
`Q
`w
`a:
`u
`x
`w
`,..
`a:
`< z
`;;:
`=>
`
`<
`"' .,:
`0
`
`Fig. 6. Iron excretion with intravenous DTPA. (A. J., 6 years.)
`
`G. D. cl
`
`:r:tor.
`
`Scrum
`Iron
`pg/ 100 .. 1
`
`Sa turat ion °/0
`
`Blood
`
`0
`
`~
`~
`.. ~
`0
`z
`"
`0
`;:
`"'
`w
`...
`a:
`u
`"'
`x
`w
`.:
`li
`~ "'
`;;:
`::>
`
`E
`
`20
`
`IS
`
`10
`
`5
`
`196S
`
`4
`
`2
`
`...
`" z
`zW - "
`!; "' "'
`..J
`w
`:r
`u
`
`172
`
`77
`
`71
`
`'42
`
`107
`
`25
`
`2so .. 1
`
`200ml 300ml
`
`250ml
`
`Sc tum Mg mcqu/I
`
`Scrum Ca mg •/o
`
`2 .6
`
`10.9
`
`2.s
`
`9.S
`
`28 29 30
`May
`
`2 3
`June
`
`9
`
`II 12 13
`July
`
`9 10
`
`II 12
`l.C
`Sept<mbcr
`
`IS
`
`DES F
`
`DTPA
`
`DTPA
`
`DESF
`
`DTPA
`
`D ES F
`
`D.E.S.F. ' Oulerrloxamlnc
`
`0. T. P.A. ' Olethylene tr la,. Inc pcnta acetic acid
`
`Fig. 7. I ron excretion with intramuscular deferoxamine and intravenous DTPA. (G. D., 1 year.)
`
`
`6 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`

`

`Volume 69 Number 4
`
`Def eroxamine and DTPA in thalassemia 5 6 9
`
`His iron intake from blood transfusions dur(cid:173)
`ing this time was 1,600 mg., so h is output
`did not quite balance his intake. In the same
`period,
`the boy's sister eliminated about
`1,400 mg. iron and received only 400 mg.
`of iron in transfusions of blood. She, there(cid:173)
`fore, had an estimated net loss of iron of
`about 1,000 rng. in the 8 month period of
`study.
`Food iron was not taken into account in
`the above patients.
`The third patient had an output of only
`130 mg. after 2 courses of Desferal (Fig. 3) .
`Between admissions, he was given 28 Gm.
`deferoxamine over 3 months by his family
`doctor. On the basis of his iron excretion in
`the hospital, his iron output per 1 Gm.
`Desferal was estimated to be only about 5
`mg., which meant about 140 mg. for the
`3 month period, or a total excretion for the
`5 months (hospital and home) of 270 mg.
`The amount of iron received during this time
`in blood transfusions was about 800 mg., so
`that his excretion was only one third of his
`iron intake. One year later, another short
`course of Desferal was rather more effec(cid:173)
`tive.
`While in the hospital for blood transfu(cid:173)
`sions in 1965 all 3 patients received 2 or
`more intravenous injections of DTPA. The
`two older children were given 4 Gm. on
`each occasion and both excreted a consider(cid:173)
`able amount of iron (Figs. 4 and 5). T hese
`charts also show that when urine was col(cid:173)
`lected for 3 consecutive days after DTPA
`was administered, practically all the excre(cid:173)
`tion of iron was accomplished during the
`first 24 hours after the preparation was
`given. T he third child received 3 Gm. of
`DTPA on 4 separate occasions (Fig. 6). On
`the first and second times, it was given in
`the transfused blood, while on the third and
`fourth, the vehicle for the DTP A was 5 per
`cent dextrose solution. It is not clear why so
`little iron was removed at the second at(cid:173)
`tempt, nor whether the increased output
`after the third and fourth treatments was
`due to the different. diluent used, or if this
`was merely fortuitO\.ls.
`T he foui:th patient has been given both
`
`Desferal and DTP A on each of three short
`visits to the hospital (Fig. 7) . The dose of
`Desferal has been from 0.5 to 2 Gm. and
`that of DTP A 2 Gm. in 5 per cent dextrose
`water. This child's iron output has been
`rather small as compared with that of the
`other patients.
`
`DIS C USS ION
`
`Normal children have a daily urinary iron
`excretion of about 0.1 mg. This may rise to
`0.5 mg. in states of severe iron overload
`and may be considerably increased by ef(cid:173)
`ficient iron chelating agents. In normal per(cid:173)
`sons, however, these preparations have little
`effect on excretion of iron. 7• 13
`In our patients, both deferoxamine and
`DTPA proved effective when the iron over(cid:173)
`load was heavy. While optimum dosage was
`not established, it was decided not to ex(cid:173)
`ceed 200 mg. per kilogram of body weight
`with either preparation. DTPA given slowly
`at the time of blood transfusion did not give
`rise to any ill effects, and the intervals be(cid:173)
`tween doses were such that magnesium de(cid:173)
`pletion was unlikely. For long-term therapy,
`DTP A given at the time of transfusion, and
`deferoxarnine in between, as recommended
`by Sephton Srnith,18 is probably the best
`method. An effective oral preparation would
`be a great advantage, but at present no such
`product is available. It is true that about
`10 per cent of deferoxamine is absorbed
`from the intestinal tract, but to achieve the
`absorption of 1 Gm., 10 Gm. ( 40 capsules)
`would have to be swallowed daily and it
`is unlikely that this regimen would be fol(cid:173)
`lowed for very long. As indicated, our best
`results were in the children with the great(cid:173)
`est iron load, but when the demands for
`blood were high, even continuous treatment
`did not achieve an excretion of iron which
`equaled
`the amount entering
`the body.
`The stored body iron was, therefore, not
`reduced but at least the accumulation of
`more iron was largely prevented. As treat(cid:173)
`ment continued, there was a tendency for
`the urinary iron output to decrease, suggest(cid:173)
`ing that the chelating agents had become
`less effective.
`
`
`7 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`

`

`5 7 0 McDonald
`
`October 1966
`
`In our youngest patient, we started ther(cid:173)
`apy early, hoping to get rid of iron more or
`less as it was administered in blood and so
`prevent its accumulation. Unfortunately this
`hope was not realized and it was apparent
`that chelating agents do not remove much
`iron unless a large excess is present.
`In order to limit iron intake, we withhold
`blood transfusion until the patient's hemo(cid:173)
`globin has fallen to about 6 Gm. per hun(cid:173)
`dred ml. or when symptoms of anemia have
`appeared. Wolman,19 however, advanced the
`view that keeping the hemoglobin level high
`by frequent transfusions will result in better
`health and less enlargement of liver and
`heart in thalassemic patients. He suggested
`that maintenance of a high serum hemoglo(cid:173)
`bin would mean less demand for new blood
`formation and, therefore, less iron absorp(cid:173)
`tion from the gastrointestinal tract. This
`point is controversial, and whether true or
`not, the fact cannot be escaped that more
`frequent blood transfusion must inevitably
`result in increased iron retention.
`Treatment of these thalassemic children
`has to be continued more or less indefinitely,
`and much patience and perseverance on the
`part of both patient and doctor are required.
`Although our over-all results were not
`very spectacular, the treatment as outlined
`seems worth a trial in children 'vith severe
`iron overload, at least until something better
`is available; but good results are not to be
`expected unless the accumulation of iron in
`the body is considerable.
`
`SUMMARY
`
`An account is given of the use of deferox(cid:173)
`amine and diethylenetriaminepentaacetic acid
`in 4 children with thalassemia major. Both
`preparations increased the urinary output
`of iron, the best results being obtained in
`the children with the heaviest iron overload.
`An attempt to prevent accumulation of
`iron by using the preparations early in the
`illness was unsuccessful in the single patient
`in whom this was tried.
`Dosage and method of use of chelating
`agents in patients with thalassernia major
`are discussed and the view expressed that
`
`even if not a great deal of iron is eliminated
`this form of treatment is worthwhile as there
`is, at present, no other practicable means for
`increasing excretion of iron.
`Professor J. Kench and his stalf. of the De(cid:173)
`partment of Chemical Pathology, particularly
`Dr. L. Kahn, are thanked for the iron deter(cid:173)
`rninations and for inf~nnation regarding meth(cid:173)
`ods used. The charts were prepared by Miss C.
`Freescmann and photographed by Mr. B. Todt,
`while help in the preparation of the manuscript
`was given by Mrs. 0. M. Cartwright. All are
`thanked for their assistance, as is Professor F. J.
`Ford for his interest, the nursing and medical
`staff for the many urine and blood collections,
`and Dr. J. G. Burger, Medical Superintendent,
`for permission to publish this report.
`
`REFERENCES
`
`1. Engle, M . A.: Cardiac involvement in Cooley's
`anemia, Ann. New Yoi·k Acad. Sc. 119-: 641,
`1964.
`2. Wohler, F.: The treatment of haemochroma(cid:173)
`tosis with desferrioxamine, Acta hae.mat. 30:
`65, 1963.
`3. Moeschlin, S.: Leiter: Erfahrungen mit Des(cid:173)
`fer rioxamin bei pathologischen Eisenablager(cid:173)
`ungen: Gespriich am runden Tisch, Schweiz.
`med. Wchnschr. 92: 1295, 1962.
`4. Henderson, F., Viett.i, T. J., and Brown, E.
`B.: Desferrioxa.mine in the treatment of acute
`toxic reaction to ferrous gluconate, J. A. M.A.
`186: 1139, 1963.
`5. Santos, A. S., and Pisciotta, A. V.: Acute
`iron intoxication. Treatment with desferriox(cid:173)
`amine, Am. J. Dis. Child. 107: 424, 1964.
`6. Shapirn, N., and Barbezat, G. 0.: A case of
`acute iron poisoning treated with desferriox(cid:173)
`amine B, South African M. J. 38: 461, 1964.
`7. Moeschlin, S., and Schnider, U.: Treatment
`of primary and secondary hemochromatosis
`and acute iron poisoning with a new potent
`iron eliminating agent ( desferrioxamine B),
`New England J. Med. 269: 57, 1963.
`8. Bannerman, R. M., Callender, S. T., and
`Williams, D . L.: Effect of desferrioxamine
`and D.T.P.A. in iron overload, Brit. M. J.
`2: 1573, 1962.
`9. Sephton Smith, R.: Iron excretion in thalas·
`saemia major after administration of chelat(cid:173)
`ing agents, Brit. M. J. 2: 1577, 1962.
`1'~ahey, J. L., Rath, C. E., Princiotto, J. V.,
`Brick, I. B., and Rubin, M.: Evaluation of
`trisodium calcium diethylenetriaminepcnta·
`acetate in iron storage disease, J. Lab. &
`Clin. Med. 57: 436, 1961.
`11. Muller-Eberhard, U., Erlandson, M. E., Ginn,
`H . E., and Smith, C. H.: Effects of trisodium
`calcium diethylenetriamine-pentaacetate on
`bivalent cations in thalassaemia major, Blood
`22: 209, 1963.
`
`10.
`
`
`8 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`

`

`Volume 69 Numb1r 4
`
`Deferoxamine and DTPA in thalassemia 5 7 l
`
`.E. F., Maxwell, G. M ., and
`J 2. R obertson,
`Elliott, R. B.: Studies in thalassacmia major,
`M. J. Australia 2: 705, 1963.
`J3. Brick, I. B., and R ath, C. E.: Ciba sympo(cid:173)
`sium on iron metabolism: Evaluation of tri(cid:173)
`sodium calcium dielhylenc-triamine penta(cid:173)
`acetate in haemochromatosis and transfusion
`haemosiderosis, Berlin, Springer-Verlag, 1964,
`p. 568.
`!4. Stevens, E., R osoff, B., Weiner, M., and
`Spencer, H .: Metabolism of the chelating
`agent diethylcnetriamine pentaacetic acid
`( C14DTPA) in man, Proc. Soc. Exper. Biol.
`& Med. J J 1: 235, 1962.
`JS. Malpas, J. S.: Dcsfcrrioxamine, Practitioner
`195: 369, 1965.
`
`16. Erlandson, M. E., Golubow, J., Wehman, J.,
`and Smith, C. H.: Metabolism of iron, cal(cid:173)
`cium and magnesium in homozygous thalas(cid:173)
`saemia, Ann. New York Acad. Sc. 119: 769,
`1964.
`17. K ahn, L. B.: D etermination of desferriox(cid:173)
`amine-bound iron in urine, South African
`M. J. 38: 463, 1964.
`18. Sephton Smith, R.: Personal communication,
`1964.
`I. J.: Tr.insfusion
`therapy m
`19. vVolman,
`Cooley's anemia: Growth and health as 1-e(cid:173)
`lated to long range hemoglobin levels, Ann.
`New York Acad. Sc. 11 9: 736, 1964.
`
`
`9 of 9
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1028
`
`