November 2023: Thalidomide for Recurrent Bleeding Due to Small-Intestinal Angiodysplasia
The issue
Recurrent bleeding from small‑intestinal angiodysplasia (SIA) is difficult to control and is responsible for 5–10 % of all gastrointestinal bleeds in older adults.
What do I need to know?
In a multicenter, double‑blind trial, 150 people who had ≥ 4 bleeding episodes in the previous year were randomized to thalidomide 100 mg, thalidomide 50 mg, or placebo for four months and then followed for a year. An “effective response” (≥ 50 % fewer bleeding episodes than the year before treatment) occurred in 68.6 % of patients on 100 mg, 51.0 % on 50 mg, and 16.0 % on placebo. The drug also sharply cut transfusions and bleeding‑related hospitalizations. Side‑effects were common but mild (constipation, somnolence, limb numbness, peripheral edema, dizziness, elevated liver enzymes); 68.6 % of the 100 mg group and 55.1 % of the 50 mg group reported at least one adverse event versus 28.0 % with placebo. All events were grade 1‑2 and resolved after treatment stopped.
Potential risk of SIA‑related bleeding
An older adult with iron‑deficiency anemia or a single occult‑blood–positive stool but ≤ 3 bleeding episodes in the past year.
Recommended Actions
Monitor hemoglobin, ferritin, and stools every three to six months.
Optimize non‑invasive measures (iron supplementation, proton‑pump inhibitor if indicated).
Discuss capsule endoscopy or balloon enteroscopy if anemia persists.
Imminent risk of recurrent bleeding
Four or more bleeding episodes in a year without transfusion or hospitalization.
Recommended Actions
Ask the gastroenterologist whether short‑course thalidomide (50 mg) is appropriate and review contraindications (pregnancy potential, neuropathy).
Continue iron therapy and schedule endoscopic evaluation to ablate visible lesions where feasible.
Track bowel‑color diary and fecal occult‑blood tests as instructed.
Confirmed high‑risk bleeding
Frequent or severe episodes requiring transfusion, hospital stay, or causing symptomatic anemia.
Recommended Actions
Consider thalidomide 100 mg daily for four months, with monthly labs (CBC, liver enzymes) and neuropathy checks.
Combine with somatostatin analogues or endoscopic therapy if lesions are accessible.
Discontinue thalidomide and seek alternatives (e.g., octreotide, angiographic embolization) if grade 2 side‑effects persist.
What can I do?
Ask your doctor, “Am I at potential, imminent, or confirmed risk, and would a four‑month thalidomide course help me bleed less?” Keep a diary of stool color, dizziness, or fatigue, and bring transfusion records to appointments. During therapy, take tablets exactly as prescribed, avoid pregnancy (mandatory for women of child‑bearing potential), and report constipation, numbness, or swelling promptly so doses can be adjusted or stopped early. Family members can help track pill counts and accompany the patient to monthly lab checks to ensure benefits outweigh risks.
