OBJECTIVES: Sickle cell disease (SCD), an inherited hemoglobinopathy that causes anemia, severe pain, vaso-occlusive crisis (VOC), is currently recognized as a global public health concern, being the leading cause of pediatric stroke. Our aim was to synthesize the evidence on the efficacy and safety of interventions for managing SCD in this population.

METHODS: A systematic review with searches in PubMed, Scopus, and Web of Science was performed (April-2022). Randomized controlled trials comparing disease modifying agents in SCD patients under 18 years old were included. For each outcome of interest, data were pooled by means of Bayesian network meta-analyses with surface under the cumulative ranking curve analyses (SUCRA). Results were reported as odds ratio (OR) with 95% credibility intervals (CrI).

RESULTS: Seventeen trials (1982-2022) mostly from African countries (65%) and North America (53%), assessing the effect of different interventions’ regimens (hydroxyurea [n=6 trials], L-arginine [n=3], antiplatelets [n=2], immunotherapy/monoclonal antibodies [n=2], sulphates [n=2], docosahexaenoic acid [n=1], niprisan [n=1]) and placebo were included. No statistical differences among treatments were found for the main outcomes. SUCRA revealed that immunotherapy/monoclonal antibodies and hydroxyurea 20 mg/kg are potentially more effective against acute chest syndrome (83% and 76% probabilities, respectively), VOC (71% and 80%, respectively) and needing of transfusions (72% and 75%, respectively), while L-arginine (100-200 mg/kg) and placebo were more prone to these events. Although therapies were overall considered safe, antiplatelet and sulphates may lead to more discontinuations and severe adverse events (uncertainty evidence). Results were similar between age subgroups (<10 years vs. 10-19 years).

CONCLUSIONS: The available evidence on the effect of drugs for managing SCD in children and adolescents is insufficient and weak. No clear definition for some outcomes exists. Hydroxyurea may remain the standard of care for this population, however, long-term well-designed and well-reported trials comparing new immunotherapy/monoclonal antibodies should be performed.