Synergistic Potential of Thalidomide and Hydroxyurea in Sickle Cell Disease Management: A Promising Combination...

Sickle Cell Disease (SCD) and β-thalassemia are hemoglobinopathies characterized by significant morbidity and mortality due to defective hemoglobin production, chronic anemia, and systemic complications. Pharmacological agents such as hydroxyurea and thalidomide have demonstrated efficacy in managing these disorders by modulating fetal hemoglobin (HbF) levels and alleviating disease severity. Hydroxyurea, a well-established therapy, increases HbF production by stimulating gamma-globin synthesis and reducing hemoglobin S (HbS) polymerization. In SCD, it mitigates vaso-occlusive crises, acute chest syndrome, and anemia by stabilizing red blood cells, decreasing neutrophil and platelet counts, and promoting nitric oxide-mediated vasodilation. In β-thalassemia, hydroxyurea improves erythropoiesis, reduces transfusion dependency, and alleviates extramedullary hematopoiesis. Thalidomide, an emerging agent, induces HbF through transcriptional regulation of gamma-globin genes by inhibiting BCL11A and activating erythroid Krüppel-like factor (KLF1). It has shown significant efficacy in increasing HbF levels, particularly in β-thalassemia, where it also improves anemia, reduces ineffective erythropoiesis, and lessens transfusion requirements. Additionally, thalidomide's anti-inflammatory effects, mediated by suppression of pro-inflammatory cytokines like TNF-α, may contribute to its therapeutic benefits in SCD. The synergistic action of hydroxyurea and thalidomide presents a promising approach for optimizing treatment outcomes, as their combined effects on HbF induction and inflammation modulation may enhance clinical benefits. While hydroxyurea remains the cornerstone of SCD therapy, thalidomide offers promise as a complementary or alternative treatment, especially for β-thalassemia patients unresponsive to conventional approaches. This review discusses the molecular mechanisms, clinical benefits, and limitations of hydroxyurea and thalidomide in SCD and β-thalassemia, highlighting their potential for optimizing therapeutic strategies in these hemoglobinopathies.