Thalidomide (pronounced /θəˈlɪdəmaɪd/ ) is a sedative-hypnotic and multiple myeloma medication. The drug is a potent teratogen in rabbits and primates including humans: severe birth defects may result if the drug is taken during pregnancy.
Thalidomide was sold in a number of countries across the world from 1957 until 1961 when it was withdrawn from the market after being found to be a cause of birth defects in what has been called "one of the biggest medical tragedies of modern times". It is not known exactly how many worldwide victims of the drug there have been, although estimates range from 10,000 to 20,000. Since then thalidomide has been found to be a valuable treatment for a number of medical conditions and it is being prescribed again in a number of countries, although its use remains controversial. The thalidomide tragedy led to much stricter testing being required for drugs and pesticides before they can be licensed.
History
Development
Thalidomide was said to have been developed by German pharmaceutical company Grünenthal in Stolberg (Rhineland) near Aachen, although this claim has recently been challenged. A report published by Dr Martin W Johnson, director of the Thalidomide Trust in the United Kingdom, detailed evidence that suggested the drug had been developed as an antidote to nerve gases such as sarin in Germany in 1944, ten years before Grünenthal secured a patent in 1954. Other sources have suggested that it may have been first synthesised by British scientists at the University of Nottingham in 1949. Thalidomide, launched by Grünenthal on 1st october 1957, was found to act as an effective tranquiliser and painkiller and was proclaimed as a "wonder drug" for insomnia, coughs, colds and headaches. It was also found to be an effective antiemetic which had an inhibitory effect on morning sickness, and so thousands of pregnant women took the drug to relieve their symptoms. At the time of the drug's development it was not thought likely that any drug could pass from the mother across the placental barrier and harm the developing fetus.
Birth defects
In the late 1950s and early 1960s, more than 10,000 children in 46 countries were born with deformities such as phocomelia, as a consequence of thalidomide use. The Australian obstetrician William McBride and the German pediatrician Widukind Lenz suspected a link between birth defects and the drug, and this was proved by Lenz in 1961. McBride was later awarded a number of honours including a medal and prize money by the prestigious L'Institut de la Vie in Paris.
In the United Kingdom the drug was licensed in 1958 and, of the babies born with defects, 456 survived. The drug was withdrawn in 1961 but it was not until 1968, after a long campaign by The Sunday Times newspaper, that a compensation settlement for the UK victims was reached with Distillers Company Limited. In Germany approximately 2,500 thalidomide babies were born.
The impact in the United States was minimized when pharmacologist and M.D. Frances Oldham Kelsey refused Food and Drug Administration (FDA) approval for an application from Richardson Merrell to market thalidomide, saying more study was needed. Richardson Merrell gave the tablets to doctors on the understanding that the drug was still under investigation. Seventeen children were born in the U.S. with the defects.
In 1962, the United States Congress enacted laws requiring tests for safety during pregnancy before a drug can receive approval for sale in the U.S. Other countries enacted similar legislation, and thalidomide was not prescribed or sold for decades.
Mechanism
It was soon discovered that only one particular optical isomer of thalidomide caused the teratogenicity. The pair of enantiomers, while mirror images of each other, cause different effects, although it is now known that the "safe" isomer can be converted to the teratogenic isomer once in the human body.(see Teratogenic mechanism ).
Revived interest
In 1964 Jacob Sheskin, Professor at the Hebrew University of Jerusalem at Hadassah University Hospital (he was also the chief staff and manager of Hansen Leper Hospital in Jerusalem), administered thalidomide to a critically ill patient with erythema nodosum leprosum (ENL), a painful complication of leprosy, in an attempt to relieve his pain in spite of the ban. The patient slept for hours, and was able to get out of bed without aid upon awakening. The result was followed by more favorable experiences and then by a clinical trial.
He found that patients with erythema nodosum leprosum, a painful skin condition, experienced relief of their pain by taking thalidomide. Further work conducted in 1991 by Dr. Gilla Kaplan at Rockefeller University in New York City showed that thalidomide worked in leprosy by inhibiting tumor necrosis factor alpha. Kaplan partnered with Celgene Corporation to further develop the potential for thalidomide. Subsequent research has shown that thalidomide is effective in the treatment of multiple myeloma, and it was approved for use in the United States by the FDA for use in this malignancy. The FDA has also since approved the drug's use in the treatment of erythema nodosum leprosum. There are studies underway to determine the drug's effects on arachnoiditis and several types of cancers. However, physicians and patients alike must go through a special process to prescribe and receive thalidomide (S.T.E.P.S) to ensure no more children are born with birth defects traceable to the medication. Celgene Corporation has also developed analogues to thalidomide, such as lenalidomide, that are substantially more powerful and have fewer side effects - except for greater myelosuppression.
United States
On July 16, 1998, the FDA approved the use of thalidomide for the treatment of lesions associated with Erythema Nodosum Leprosum (ENL). Because of thalidomide’s potential for causing birth defects, the distribution of the drug was permitted only under tightly controlled conditions. The FDA required that Celgene Corporation, which planned to market thalidomide under the brand name Thalomid , establish a System for Thalidomide Education and Prescribing Safety (S.T.E.P.S) oversight program. The conditions required under the program include; limiting prescription and dispensing rights only to authorized prescribers and pharmacies, keeping a registry of all patients prescribed thalidomide, providing extensive patient education about the risks associated with the drug and providing periodic pregnancy tests for women who are prescribed it. On May 26, 2006, the U.S. Food and Drug Administration granted accelerated approval for thalidomide (Thalomid, Celgene Corporation) in combination with dexamethasone for the treatment of newly diagnosed multiple myeloma (MM) patients. The FDA approval came seven years after the first reports of efficacy in the medical literature and Celgene took advantage of "off-label" marketing opportunities to promote the drug in advance of its FDA approval for the myeloma indication. Thalomid, as the drug is commercially known, sold over $300 million per year, while only approved for leprosy.
United Kingdom
Thalidomide is available to only a small number of patients in the UK, generally in specialist cancer treatment centres where research trials are taking place and specialist doctors have experience in its use.
Brazil
Brazil has the highest prevalence rate of leprosy in the world and thalidomide has been used by Brazilian physicians as the drug of choice for the treatment of severe ENL since 1965. A study published in 1994 found 61 people born after 1965 whose limb defects and exposure history were compatible with thalidomide embryopathy. In 63.6% of these cases, thalidomide had been prescribed without the physician informing the patient about the drug's teratogenicity. Since then production, dispensing and prescription of thalidomide have been strictly controlled and no cases of thalidomide embryopathy are thought to have occurred since 1997.
Possible indications
Research on thalidomide slowed in the 1960s, but never stopped. At least one university in the United States pursues thalidomide research, even though performed by only one tenured professor. The medication is an example of how potentially dangerous compounds can be used therapeutically with appropriate precautions and procedures.
Serious infections including sepsis and tuberculosis cause the level of Tumor necrosis factor-alpha (TNFα) to rise. TNFα is a chemical mediator in the body, and it may enhance the wasting process in cancer patients as well. Thalidomide may reduce the levels of TNFα, and it is possible that the drug's effect on ENL is caused by this mechanism.
Thalidomide also has potent anti-inflammatory effects that may help ENL patients. In July 1998, the FDA approved the application of Celgene to distribute thalidomide under the brand name Thalomid for treatment of ENL. Pharmion Corporation, who licensed the rights to market Thalidomide in Europe, Australia and various other territories from Celgene, received approval for its use against multiple myeloma in Australia and New Zealan
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