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Palandri F, Auteri G, Abruzzese E, Caocci G, Bonifacio M, Mendicino F, Latagliata R, Iurlo A, Branzanti F, Garibaldi B, Trawinska MM, Cattaneo D, Krampera M, Mulas O, Martino EA, Cavo M, Vianelli N, Impera S, Efficace F, Heidel F, Breccia M, Elli EM, Palumbo GA. Ruxolitinib Adherence in Myelofibrosis and Polycythemia Vera: the "RAMP" Italian multicenter prospective study. Ann Hematol 2024; 103:1931-1940. [PMID: 38478023 DOI: 10.1007/s00277-024-05704-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/09/2024] [Indexed: 05/14/2024]
Abstract
Ruxolitinib is beneficial in patients with myelofibrosis (MF) and polycythemia vera (PV). Information on ruxolitinib adherence is scant. The Ruxolitinib Adherence in Myelofibrosis and Polycythemia Vera (RAMP) prospective multicenter study (NCT06078319) included 189 ruxolitinib-treated patients. Patients completed the Adherence to Refills and Medications Scale (ARMS) and Distress Thermometer and Problem List (DTPL) at the earliest convenience, after registration in the study, and at later timepoints. At week-0, low adherence (ARMS > 14) and high distress (DT ≥ 4) were declared by 49.7% and 40.2% of patients, respectively. The main reason for low adherence was difficult ruxolitinib supply (49%), intentional (4.3%) and unintentional (46.7%) non-take. In multivariable regression analysis, low adherence was associated to male sex (p = 0.001), high distress (p < 0.001), and treatment duration ≥ 1 year (p = 0.03). Over time, rates of low adherence and high distress remained stable, but unintentional non-take decreased from 47.9% to 26.0% at week-48. MF patients with stable high adherence/low distress were more likely to obtain/maintain the spleen response at week-24. Low adherence to ruxolitinib represents an unmet clinical need that require a multifaceted approach, based on reason behind it (patients characteristics and treatment duration). Its recognition may help distinguishing patients who are truly refractory and those in need of therapy optimization.
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Affiliation(s)
- F Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy.
| | - G Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - E Abruzzese
- Hematology, S.Eugenio Hospital, Tor Vergata University, ASL Roma2, Rome, Italy
| | - G Caocci
- Hematology Unit, Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - M Bonifacio
- Hematology and Bone Marrow Transplant Unit, Section of Biomedicine of Innovation, Department of Engineering for Innovative Medicine, University of Verona, Verona, Italy
| | - F Mendicino
- U.O.C. Di Ematologia, Department of Hemato-Oncology, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - R Latagliata
- Hematology Unit, Ospedale Belcolle, Viterbo, Italy
| | - A Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F Branzanti
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - B Garibaldi
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - M M Trawinska
- Hematology, S.Eugenio Hospital, Tor Vergata University, ASL Roma2, Rome, Italy
| | - D Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Krampera
- Hematology and Bone Marrow Transplant Unit, Section of Biomedicine of Innovation, Department of Engineering for Innovative Medicine, University of Verona, Verona, Italy
| | - O Mulas
- Hematology Unit, Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - E A Martino
- U.O.C. Di Ematologia, Department of Hemato-Oncology, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - M Cavo
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - N Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
| | - S Impera
- Department of Hematology, ARNAS Garibaldi, Catania, Italy
| | - F Efficace
- Data Center and Health Outcomes Research Unit, Italian Group for Adult Hematologic Diseases (GIMEMA), Rome, Italy
| | - F Heidel
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School (MHH), Hannover, Germany
| | - M Breccia
- Division of Cellular Biotechnologies and Hematology, University Sapienza, Rome, Italy
| | - E M Elli
- Divisione di Ematologia e Unità Trapianto di Midollo, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - G A Palumbo
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia", Università Di Catania, Catania, Italy
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Chojecki A, Boselli D, Dortilus A, Hamadeh I, Begley S, Chen T, Bose R, Podoltsev N, Zeidan AM, Balmaceda NB, Yacoub A, Ai J, Knight TG, Ragon BK, Shah NA, Sanikommu SR, Symanowski J, Mesa R, Grunwald MR. Hematocrit control and thrombotic risk in patients with polycythemia vera treated with ruxolitinib in clinical practice. Ann Hematol 2024:10.1007/s00277-024-05735-7. [PMID: 38662203 DOI: 10.1007/s00277-024-05735-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/29/2024] [Indexed: 04/26/2024]
Abstract
Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by unregulated red blood cell production resulting in elevated hemoglobin and/or hematocrit levels. Patients often have symptoms such as fatigue, pruritus, and painful splenomegaly, but are also at risk of thrombosis, both venous and arterial. Ruxolitinib, a selective Janus kinase inhibitor, is approved by the US Food and Drug Administration as second-line cytoreductive treatment after intolerance or inadequate response to hydroxyurea. Although ruxolitinib has been widely used in this setting, limited data exist in the literature on ruxolitinib treatment patterns and outcomes among patients with PV in routine clinical practice. We report a retrospective, observational, cohort study of patients treated for PV with ruxolitinib across three US centers (academic and regional practice) from December 2014-December 2019. The study included 69 patients, with a median follow-up duration of 3.7 years (95% CI, 2.9-4.4). Our data demonstrate very high rates of hematocrit control (88% of patients by three months and 89% by six months); few patients required dose adjustments or suspension. No arterial thromboses were observed; however, the follow-up duration does not allow for the generation of meaningful conclusions from this. Three patients had thrombotic events; one was in the setting of a second malignancy, one post-operative, and a third related to prolonged immobility. We also found that 28% of patients initiated ruxolitinib as a result of poorly controlled platelet counts, second only to hydroxyurea intolerance (46%) as a reason to start therapy. In clinical practice, ruxolitinib continues to be effective in controlling hematocrit levels after three and six months of treatment in patients and is associated with low thrombotic risk.
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Affiliation(s)
- Aleksander Chojecki
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute, Wake Forest University School of Medicine, Charlotte, NC, USA.
| | - Danielle Boselli
- Department of Biostatistics and Data Sciences, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Allison Dortilus
- Department of Biostatistics and Data Sciences, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Issam Hamadeh
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephanie Begley
- Department of Biostatistics and Data Sciences, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Tommy Chen
- Department of Biostatistics and Data Sciences, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Rupali Bose
- Department of Biostatistics and Data Sciences, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Nikolai Podoltsev
- Hematology Section, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Amer M Zeidan
- Hematology Section, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Nicole Baranda Balmaceda
- Department of Hematologic Malignancies and Cellular Therapies, Kansas University, Kansas City, KS, USA
| | - Abdulraheem Yacoub
- Department of Hematologic Malignancies and Cellular Therapies, Kansas University, Kansas City, KS, USA
| | - Jing Ai
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute, Wake Forest University School of Medicine, Charlotte, NC, USA
| | - Thomas Gregory Knight
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute, Wake Forest University School of Medicine, Charlotte, NC, USA
| | - Brittany Knick Ragon
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute, Wake Forest University School of Medicine, Charlotte, NC, USA
| | - Nilay Arvind Shah
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute, Wake Forest University School of Medicine, Charlotte, NC, USA
| | - Srinivasa Reddy Sanikommu
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute, Wake Forest University School of Medicine, Charlotte, NC, USA
| | - James Symanowski
- Department of Biostatistics and Data Sciences, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Ruben Mesa
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute, Wake Forest University School of Medicine, Charlotte, NC, USA
| | - Michael Richard Grunwald
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Institute, Wake Forest University School of Medicine, Charlotte, NC, USA
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Alvarez-Larrán A, Garrote M, Ferrer-Marín F, Pérez-Encinas M, Mata-Vazquez MI, Bellosillo B, Arellano-Rodrigo E, Gómez M, García R, García-Gutiérrez V, Gasior M, Cuevas B, Angona A, Gómez-Casares MT, Martínez CM, Magro E, Ayala R, Del Orbe-Barreto R, Pérez-López R, Fox ML, Raya JM, Guerrero L, García-Hernández C, Caballero G, Murillo I, Xicoy B, Ramírez MJ, Carreño-Tarragona G, Hernández-Boluda JC, Pereira A. Real-world analysis of main clinical outcomes in patients with polycythemia vera treated with ruxolitinib or best available therapy after developing resistance/intolerance to hydroxyurea. Cancer 2022; 128:2441-2448. [PMID: 35417564 PMCID: PMC9324831 DOI: 10.1002/cncr.34195] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022]
Abstract
Background Ruxolitinib is approved for patients with polycythemia vera (PV) who are resistant/intolerant to hydroxyurea, but its impact on preventing thrombosis or disease‐progression is unknown. Methods A retrospective, real‐world analysis was performed on the outcomes of 377 patients with resistance/intolerance to hydroxyurea from the Spanish Registry of Polycythemia Vera according to subsequent treatment with ruxolitinib (n = 105) or the best available therapy (BAT; n = 272). Survival probabilities and rates of thrombosis, hemorrhage, acute myeloid leukemia, myelofibrosis, and second primary cancers were calculated according to treatment. To minimize biases in treatment allocation, all results were adjusted by a propensity score for receiving ruxolitinib or BAT. Results Patients receiving ruxolitinib had a significantly lower rate of arterial thrombosis than those on BAT (0.4% vs 2.3% per year; P = .03), and this persisted as a trend after adjustment for the propensity to have received the drug (incidence rate ratio, 0.18; 95% confidence interval, 0.02‐1.3; P = .09). There were no significant differences in the rates of venous thrombosis (0.8% and 1.1% for ruxolitinib and BAT, respectively; P = .7) and major bleeding (0.8% and 0.9%, respectively; P = .9). Ruxolitinib exposure was not associated with a higher rate of second primary cancers, including all types of neoplasia, noncutaneous cancers, and nonmelanoma skin cancers. After a median follow‐up of 3.5 years, there were no differences in survival or progression to acute leukemia or myelofibrosis between the 2 groups. Conclusions The results suggest that ruxolitinib treatment for PV patients with resistance/intolerance to hydroxyurea may reduce the incidence of arterial thrombosis. Lay Summary Ruxolitinib is better than other available therapies in achieving hematocrit control and symptom relief in patients with polycythemia vera who are resistant/intolerant to hydroxyurea, but we still do not know whether ruxolitinib provides an additional benefit in preventing thrombosis or disease progression. We retrospectively studied the outcomes of 377 patients with resistance/intolerance to hydroxyurea from the Spanish Registry of Polycythemia Vera according to whether they subsequently received ruxolitinib (n = 105) or the best available therapy (n = 272). Our findings suggest that ruxolitinib could reduce the incidence of arterial thrombosis, but a disease‐modifying effect could not be demonstrated for ruxolitinib in this patient population.
Ruxolitinib may reduce the incidence of arterial thrombosis in patients with polycythemia vera resistant/intolerant to hydroxyurea.
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Affiliation(s)
- Alberto Alvarez-Larrán
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Marta Garrote
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Francisca Ferrer-Marín
- Hospital Morales Messeguer, Universidad Católica San Antonio de Murcia, Murcia, Centro de Investigación Biomédica en Red de Enfermedades Raras, Murcia, Spain
| | | | | | | | | | | | | | | | | | | | - Anna Angona
- Hospital Josep Trueta, Institut Català d'Oncologia, Girona, Spain
| | | | | | - Elena Magro
- Hospital Príncipe de Asturias, Alcalá de Henares, Spain
| | - Rosa Ayala
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - José-María Raya
- Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | | | | | | | | | - Blanca Xicoy
- Hospital Germans Trias i Pujol, Institut Català d'Oncologia, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | | | - Arturo Pereira
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
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Treatment and Clinical Endpoints in Polycythemia Vera: Seeking the Best Obtainable Version of the Truth. Blood 2022; 139:2871-2881. [PMID: 35271702 DOI: 10.1182/blood.2022015680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/26/2022] [Indexed: 11/20/2022] Open
Abstract
Polycythemia vera (PV) is a Philadelphia chromosome-negative myeloproliferative neoplasm driven by the JAK2 V617F (or rarely exon 12) mutation. Its natural history can extend over a few decades, and therefore treatment planning is predicated on continual re-assessment of traditional risk features (age, prior thrombosis) to evaluate the need for cytoreduction besides foundational therapy with low-dose aspirin and stringent phlebotomy. Shorter- and longer-term patient goals should be considered in light of several variables such as co-morbid conditions (especially cardiovascular risk factors), disease symptoms, and the risk-benefit profile of available drugs. While hydroxyurea has been the pro forma choice of cytoreduction for many practitioners over the last half-century, the more recent regulatory approvals of ruxolitinib and ropeginterferon-alfa-2b, based on phase 3 randomized trials, highlight an expanding portfolio of active drugs. Obtaining high-level evidence for short-term clinical trial endpoints such as hematocrit control, symptom burden/quality of life, splenomegaly, and JAK2 V617F allele burden lies within the timeline of most studies. However, in many cases, it may not be possible to adequately power trials to capture significant differences in the typically low event rates of thrombosis, as well as longer-horizon endpoints such as evolution to myelofibrosis and acute myeloid leukemia, and survival. This Perspective highlights the challenges of addressing these data gaps and outstanding questions in the emerging treatment landscape of PV.
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