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Chen MT, Huang ST, Lin CW, Ko BS, Chen WJ, Huang HH, Hsiao FY. Tyrosine Kinase Inhibitors and Vascular Adverse Events in Patients with Chronic Myeloid Leukemia: A Population-Based, Propensity Score-Matched Cohort Study. Oncologist 2021; 26:974-982. [PMID: 34418220 DOI: 10.1002/onco.13944] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/09/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Tyrosine kinase inhibitors (TKIs) have shown long-term survival benefits in patients with chronic myeloid leukemia (CML). Nevertheless, significant concern has been raised regarding long-term TKI-associated vascular adverse events (VAEs). The objective of this retrospective cohort study was to investigate the incidence of VAEs in Taiwanese patients with CML treated with different TKIs (imatinib, nilotinib, and dasatinib) as well as potential risk factors. MATERIALS AND METHODS We conducted a retrospective cohort study using the Taiwan Cancer Registry Database and National Health Insurance Research Database. Adult patients diagnosed with CML from 2008 to 2016 were identified and categorized into three groups according to their first-line TKI treatment (imatinib, nilotinib, and dasatinib). Propensity score matching was performed to control for potential confounders. Cox regressions were used to estimate the hazard ratio (HR) of VAEs in different TKI groups. RESULTS In total, 1,111 patients with CML were included in our study. We found that the risk of VAEs in nilotinib users was significantly higher than that in imatinib users, with an HR of 3.13 (95% confidence interval (CI), 1.30-7.51), whereas dasatinib users also showed a nonsignificant trend for developing VAEs, with an HR of 1.71 (95% CI, 0.71-4.26). In multivariable logistic regression analysis, only nilotinib usage, older age, and history of cerebrovascular diseases were identified as significant risk factors. The annual incidence rate of VAEs was highest within the first year after the initiation of TKIs. CONCLUSION These findings can support clinicians in making treatment decisions and monitoring VAEs in patients with CML in Taiwan. IMPLICATIONS FOR PRACTICE This study found that patients with chronic myeloid leukemia (CML) treated with nilotinib and dasatinib may be exposed to a higher risk of developing vascular adverse events (VAEs) compared with those treated with imatinib. Thus, this study suggests that patients with CML who are older or have a history of cerebrovascular diseases should be under close monitoring of VAEs, particularly within the first year after the initiation of tyrosine kinase inhibitors.
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Affiliation(s)
- Mei-Tsen Chen
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Shih-Tsung Huang
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Chih-Wan Lin
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Bor-Sheng Ko
- Division of Hematology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Hematological Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huai-Hsuan Huang
- Division of Hematology, National Taiwan University Hospital, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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Stuckey R, López-Rodríguez JF, Sánchez-Sosa S, Segura-Díaz A, Sánchez-Farías N, Bilbao-Sieyro C, Gómez-Casares MT. Predictive indicators of successful tyrosine kinase inhibitor discontinuation in patients with chronic myeloid leukemia. World J Clin Oncol 2020; 11:996-1007. [PMID: 33437662 PMCID: PMC7769711 DOI: 10.5306/wjco.v11.i12.996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 09/28/2020] [Accepted: 10/21/2020] [Indexed: 02/06/2023] Open
Abstract
Clinical trials have demonstrated that some patients with chronic myeloid leukemia (CML) treated for several years with tyrosine kinase inhibitors (TKIs) who have maintained a molecular response can successfully discontinue treatment without relapsing. Treatment free remission (TFR) can be reached by approximately 50% of patients who discontinue. Despite having similar levels of deep molecular response and an identical duration of treatment, the factors that influence the successful discontinuation of CML patients remain to be determined. In this review we will explore the factors identified to date that can help predict whether a patient will successfully achieve TFR. We will also discuss the need for the identification of predictive biomarkers associated with a high probability of achieving TFR for the future personalized identification of patients who are suitable for the discontinuation of TKI treatment.
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Affiliation(s)
- Ruth Stuckey
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | | | - Santiago Sánchez-Sosa
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | - Adrián Segura-Díaz
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | - Nuria Sánchez-Farías
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | - Cristina Bilbao-Sieyro
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | - María Teresa Gómez-Casares
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
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3
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Zito C, Manganaro R, Carerj S, Antonini-Canterin F, Benedetto F. Peripheral Artery Disease and Stroke. J Cardiovasc Echogr 2020; 30:S17-S25. [PMID: 32566462 PMCID: PMC7293872 DOI: 10.4103/jcecho.jcecho_4_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/23/2019] [Accepted: 10/03/2019] [Indexed: 12/21/2022] Open
Abstract
Peripheral artery disease (PAD) and stroke can occur as vascular complication of anticancer treatment. Although the mechanisms, monitoring, and management of cardiotoxicities have received broad attention, vascular toxicities remain often underrecognized. In addition, the development of new chemotherapeutic drugs bears the risk of vasotoxicities that are yet to be identified and may not be realized with short-term follow-up periods. The propensity to develop PAD and/or stroke reflects the complex interplay between patient's baseline risk and preexisting vascular disease, particularly hypertension and diabetes, while evidence for genetic predisposition is increasing. Chemotherapeutic agents with a prominent vascular side effect profile have been identified. Interruption of vascular endothelial growth factor (VEGF) inhibitors (VEGFIs) signaling (i.e., bevacizumab) is associated with vascular toxicity and clinical sequelae such as hypertension, stroke, and thromboembolism beyond acute coronary syndromes. Cisplatin and 5-fluorouracil are the main drugs involved in the stroke risk. In addition, circulating concentrations of VEGF are reduced by cyclophosphamide administered at continuous low doses, which might underpin some of the observed vascular toxicity, such as stroke, as seen in patients treated with VEGF inhibitors. The risk of stroke is also increased after treatment with anthracyclines that can induce endothelial dysfunction and increase arterial stiffness. Proteasome inhibitors ( bortezomib and carfilzomib) and immunomodulatory agents (thalidomide, lenalidomide, and pomalidomide), approved for use in multiple myeloma, carry a black box warning for an increased risk of stroke. Finally, head-and-neck radiotherapy is associated with a doubled risk of cerebrovascular ischemic event, especially if exposure occurs in childhood. The mechanisms involved in radiation vasculopathy are represented by endothelial dysfunction, medial necrosis, fibrosis, and accelerated atherosclerosis. However, BCR-ABL tyrosine kinase inhibitor (TKI), used for the treatment of chronic myeloid leukemia (CML), is the main antineoplastic drugs involved in the development of PAD. In particular, second- and third-generation TKIs, such as nilotinib and ponatinib, while emerging as a potent arm in contrasting CML, are associated with a higher risk of PAD development rather than traditional imatinib. Factors favoring vascular complication are the presence of traditional cardiovascular risk factors (CVRF) and predisposing genetic factors, high doses of BCR-ABL TKIs, longer time of drug exposure, and sequential use of potent TKIs. Therefore, accurate cardiovascular risk stratification is strongly recommended in patient candidate to anticancer treatment associated with higher risk of vascular complication, in order to reduce the incidence of PAD and stroke through CVRF correction and selection of appropriate tailored patient strategy of treatment. Then, a clinical follow-up, eventually associated with instrumental evaluation through vascular ultrasound, should be performed.
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Affiliation(s)
- Concetta Zito
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino", Messina, Italy
| | - Roberta Manganaro
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino", Messina, Italy
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino", Messina, Italy
| | | | - Frank Benedetto
- Cardiology Department, Hospital 'Bianchi Melacrino Morelli' Reggio Calabria, Italy
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Cole AL, Wood WA, Muluneh B, Lund JL, Elston Lafata J, Dusetzina SB. Comparative Safety and Health Care Expenditures Among Patients With Chronic Myeloid Leukemia Initiating First-Line Imatinib, Dasatinib, or Nilotinib. JCO Oncol Pract 2020; 16:e443-e455. [PMID: 32196424 DOI: 10.1200/jop.19.00301] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Tyrosine kinase inhibitors (TKIs) have dramatically improved survival for patients with chronic myeloid leukemia (CML). No overall survival differences were observed between patients initiating first- and second-generation TKIs in trials; however, real-world safety and cost outcomes are unclear. We evaluated comparative safety and health care expenditures between first-line imatinib, dasatinib, and nilotinib among patients with CML. PATIENTS AND METHODS Eligible patients had one or more fills for imatinib, dasatinib, or nilotinib in the MarketScan Commercial and Medicare Supplemental databases between January 1, 2011, and December 31, 2016 (earliest fill is the index date), 6 months pre-index continuous enrollment, CML diagnosis, and no TKI use in the pre-index period. Hospitalizations or emergency department visits (safety events) were compared across treatment groups using propensity-score-weighted 1-year relative risks (RRs) and subdistribution hazard ratios (HRs). Inflation-adjusted annual health care expenditures were compared using quantile regression. RESULTS Eligible patients included 1,417 receiving imatinib, 1,067 receiving dasatinib, and 647 receiving nilotinib. The 1-year risk of safety events was high: imatinib, 37%; dasatinib, 44%; and nilotinib, 40%, with higher risks among patients receiving dasatinib (RR, 1.17; 95% CI, 1.06 to 1.30) and nilotinib (RR, 1.07; 95% CI, 0.93 to 1.23) compared with those receiving imatinib. Over a median of 1.7 years, the cumulative incidence of safety events was higher among patients receiving dasatinib (HR, 1.23; 95% CI, 1.10 to 1.38) and nilotinib (HR, 1.08; 95% CI, 0.95 to 1.24) than among those receiving imatinib. One-year health care expenditures were high (median, $125,987) and were significantly higher among patients initiating second-generation TKIs compared with those receiving imatinib (difference in medians: dasatinib v imatinib, $22,393; 95% CI, $17,068 to $27,718; nilotinib v imatinib, $19,463; 95% CI, $14,689 to $24,236). CONCLUSION Patients receiving imatinib had the lowest risk of hospitalization or emergency department visits and 1-year health care expenditures. Given a lack of significant differences in overall survival, imatinib may represent the ideal first-line therapy for patients, on average.
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Affiliation(s)
- Ashley L Cole
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina (UNC) Eshelman School of Pharmacy, Chapel Hill, NC.,Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC
| | - William A Wood
- UNC School of Medicine, University of North Carolina, Chapel Hill, NC.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Benyam Muluneh
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC
| | - Jennifer L Lund
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC.,Department of Epidemiology, UNC Gillings School of Public Health, Chapel Hill, NC
| | - Jennifer Elston Lafata
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina (UNC) Eshelman School of Pharmacy, Chapel Hill, NC.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN.,Vanderbilt-Ingram Cancer Center, Nashville, TN
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Stecher SS, Lippl S, Stemmler HJ, Schreiber J. [Lung involvement in hematologic systemic diseases]. Internist (Berl) 2019; 59:886-897. [PMID: 30046891 DOI: 10.1007/s00108-018-0471-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pulmonary diseases can occur across the entire disease spectrum of malignant hematologic systemic diseases. Although infectious processes of the lungs are common in these immunosuppressed patient collectives, noninfectious causes account for up to half of the pulmonary manifestations found in hematologic malignancies. Besides the frequent infections including opportunistic pathogens, a broad differential diagnosis including drug-induced lung injury by cytostatic substances, cytokines, and innovative immunotherapeutic agents, rarer transfusion of blood products and intrathoracic manifestations of the hematologic malignancy itself, have to be kept in mind. Finally, vascular complications can also lead to pulmonary reactions. Early and consistent diagnostics and treatment of the bronchopulmonary, intrathoracic and vascular complications within the framwework of hematologic systemic diseases can be essential for the patient's prognosis.
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Affiliation(s)
- S-S Stecher
- Medizinische Klinik und Poliklinik II, Ludwig-Maximilians Universität München, Campus Großhadern, München, Deutschland
| | - S Lippl
- Medizinsche Klinik und Poliklinik III, Ludwig-Maximilians Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - H J Stemmler
- Medizinsche Klinik und Poliklinik III, Ludwig-Maximilians Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - J Schreiber
- Universitätsklinik für Pneumologie, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Deutschland
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Features of vascular adverse events in Japanese patients with chronic myeloid leukemia treated with tyrosine kinase inhibitors: a retrospective study of the CML Cooperative Study Group database. Ann Hematol 2018; 97:2081-2088. [PMID: 29946911 DOI: 10.1007/s00277-018-3412-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 06/20/2018] [Indexed: 01/06/2023]
Abstract
This study investigated the incidence rate and features of vascular adverse events (VAEs) in Japanese patients with chronic myeloid leukemia (CML) who were treated with tyrosine kinase inhibitors (TKIs). The analysis included 369 CML patients in the chronic or accelerated phases, selected from the CML Cooperative Study Group database; 25 events in 23 (6.2%) of these patients were VAEs. At the time of VAE incidence, nine patients were on treatment with imatinib, 12 with nilotinib, three with dasatinib, and one with bosutinib. VAE incidence comprised 13 cases of ischemic heart disease (IHD), eight of cerebral infarction (CI), and four of peripheral arterial occlusive disease (PAOD). IHD incidence rate in the study population was higher than that in the age-matched general population, particularly in nilotinib-treated patients, while CI incidence rate was almost equivalent. Compared with the Suita score, the SCORE chart and the Framingham score risk assessment tools detected more patients with high or very high risk of VAEs. In conclusion, incidence of IHD requires closer monitoring in nilotinib-treated patients. More detailed investigations for determining the most useful tool to predict VAE incidence and long-term analysis of therapy-related VAE cases are needed for improving safety during TKI therapy.
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Gover-Proaktor A, Granot G, Pasmanik-Chor M, Pasvolsky O, Shapira S, Raz O, Raanani P, Leader A. Bosutinib, dasatinib, imatinib, nilotinib, and ponatinib differentially affect the vascular molecular pathways and functionality of human endothelial cells. Leuk Lymphoma 2018; 60:189-199. [PMID: 29741440 DOI: 10.1080/10428194.2018.1466294] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The tyrosine kinase inhibitors (TKIs), nilotinib, ponatinib, and dasatinib (but not bosutinib or imatinib), are associated with vascular adverse events (VAEs) in chronic myeloid leukemia (CML). Though the mechanism is inadequately understood, an effect on vascular cells has been suggested. We investigated the effect of imatinib, nilotinib, dasatinib, bosutinib, and ponatinib on tube formation, cell viability, and gene expression of human vascular endothelial cells (HUVECs). We found a distinct genetic profile in HUVECs treated with dasatinib, ponatinib, and nilotinib compared to bosutinib and imatinib, who resembled untreated samples. However, unique gene expression and molecular pathway alterations were detected between dasatinib, ponatinib, and nilotinib. Angiogenesis/blood vessel-related pathways and HUVEC function (tube formation/viability) were adversely affected by dasatinib, ponatinib, and nilotinib but not by imatinib or bosutinib. These results correspond to the differences in VAE profiles of these TKIs, support a direct effect on vascular cells, and provide direction for future research.
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Affiliation(s)
- Ayala Gover-Proaktor
- a Felsenstein Medical Research Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Galit Granot
- a Felsenstein Medical Research Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Metsada Pasmanik-Chor
- b Bioinformatics Unit, G.S.W. Faculty of Life Sciences , Tel Aviv University , Tel Aviv , Israel
| | - Oren Pasvolsky
- c Institute of Hematology, Davidoff Cancer Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel.,d Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Saar Shapira
- a Felsenstein Medical Research Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel.,d Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Oshrat Raz
- a Felsenstein Medical Research Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Pia Raanani
- c Institute of Hematology, Davidoff Cancer Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel.,d Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Avi Leader
- c Institute of Hematology, Davidoff Cancer Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel.,d Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
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Haguet H, Douxfils J, Chatelain C, Graux C, Mullier F, Dogné JM. BCR-ABL Tyrosine Kinase Inhibitors: Which Mechanism(s) May Explain the Risk of Thrombosis? TH OPEN 2018; 2:e68-e88. [PMID: 31249931 PMCID: PMC6524858 DOI: 10.1055/s-0038-1624566] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022] Open
Abstract
Imatinib, the first-in-class BCR-ABL tyrosine kinase inhibitor (TKI), had been a revolution for the treatment of chronic myeloid leukemia (CML) and had greatly enhanced patient survival. Second- (dasatinib, nilotinib, and bosutinib) and third-generation (ponatinib) TKIs have been developed to be effective against BCR-ABL mutations making imatinib less effective. However, these treatments have been associated with arterial occlusive events. This review gathers clinical data and experiments about the pathophysiology of these arterial occlusive events with BCR-ABL TKIs. Imatinib is associated with very low rates of thrombosis, suggesting a potentially protecting cardiovascular effect of this treatment in patients with BCR-ABL CML. This protective effect might be mediated by decreased platelet secretion and activation, decreased leukocyte recruitment, and anti-inflammatory or antifibrotic effects. Clinical data have guided mechanistic studies toward alteration of platelet functions and atherosclerosis development, which might be secondary to metabolism impairment. Dasatinib, nilotinib, and ponatinib affect endothelial cells and might induce atherogenesis through increased vascular permeability. Nilotinib also impairs platelet functions and induces hyperglycemia and dyslipidemia that might contribute to atherosclerosis development. Description of the pathophysiology of arterial thrombotic events is necessary to implement risk minimization strategies.
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Affiliation(s)
- Hélène Haguet
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
| | - Christian Chatelain
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
| | - Carlos Graux
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Hematology, Yvoir, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory, Yvoir, Belgium
| | - Jean-Michel Dogné
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
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Saglio G, le Coutre P, Cortes J, Mayer J, Rowlings P, Mahon FX, Kroog G, Gooden K, Subar M, Shah NP. Evaluation of cardiovascular ischemic event rates in dasatinib-treated patients using standardized incidence ratios. Ann Hematol 2017; 96:1303-1313. [PMID: 28534184 PMCID: PMC5486782 DOI: 10.1007/s00277-017-3012-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/27/2017] [Indexed: 12/18/2022]
Abstract
With high survival rates for chronic myeloid leukemia (CML) patients treated with BCR-ABL1 tyrosine kinase inhibitors (TKIs), emerging consequences, such as arterial ischemic events, require consideration when evaluating treatment options. Cardiovascular ischemic event incidence in clinical trials was evaluated in 2712 dasatinib-treated patients with Philadelphia chromosome-positive (Ph+) leukemias from 11 first- and second-line trials (pooled), newly diagnosed CML patients treated with dasatinib or imatinib (DASISION), and prostate cancer patients treated with dasatinib or placebo plus docetaxel/prednisone (READY). Overall, 2-4% of dasatinib-treated patients had cardiovascular ischemic events. Most dasatinib-treated patients with an event had a history of and/or risk factor for atherosclerosis (pooled 77 with history/risk and event/96 with events; DASISION 8/10; READY 15/18). Most cardiovascular ischemic events occurred within 1 year of initiating dasatinib (pooled 69/96; DASISION 7/10; READY 16/18). Comparison of observed and expected event rates through standardized incidence ratios indicates that dasatinib does not increase risk for cardiovascular ischemic events compared with external reference populations.
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Affiliation(s)
- Giuseppe Saglio
- Clinical and Biological Sciences of the University of Turin, San Luigi Hospital, 10043, Orbassano-Torino, Italy.
| | - Philipp le Coutre
- Charité, Campus Virchow Klinikum, Universitätsmedizin Berlin, Berlin, Germany
| | - Jorge Cortes
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jiří Mayer
- Department of Internal Medicine, Hematology and Oncology, Masaryk University Hospital Brno, Brno, Czech Republic
| | - Philip Rowlings
- Calvary Mater Newcastle Hospital, University of Newcastle, Waratah, NSW, Australia
| | - François-Xavier Mahon
- Laboratoire d'Hématologie et Service des Maladies du Sang, Bordeaux et Institut Bergonié, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | | | | | | | - Neil P Shah
- UCSF School of Medicine, San Francisco, CA, USA
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10
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Risk factors and mechanisms contributing to TKI-induced vascular events in patients with CML. Leuk Res 2017; 59:47-54. [PMID: 28549238 DOI: 10.1016/j.leukres.2017.05.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 12/18/2022]
Abstract
Vascular adverse events (VAE) are an emerging problem in patients with chronic myeloid leukemia (CML) receiving second-generation BCR-ABL1 tyrosine kinase inhibitors (TKI). Relevant VAE comprise peripheral, cerebral, and coronary artery changes in patients receiving nilotinib, venous and arterial occlusive events during ponatinib therapy, and pulmonary hypertension in patients receiving dasatinib. Although each TKI binds to a unique profile of molecular targets in leukemic cells and vascular cells, the exact etiology of drug-induced vasculopathies remains uncertain. Recent data suggest that predisposing molecular factors, pre-existing cardiovascular risk factors as well as certain comorbidities contribute to the etiology of VAE in these patients. In addition, direct effects of these TKI on vascular endothelial cells have been demonstrated and are considered to contribute essentially to VAE evolution. In the current article, we discuss mechanisms underlying the occurrence of VAE in TKI-treated patients with CML, with special emphasis on vascular and perivascular target cells and involved molecular (vascular) targets of VAE-triggering TKI. In addition, we discuss optimal patient selection and drug selection through which the risk of occurrence of cardiovascular events can hopefully be minimized while maintaining optimal anti-leukemic effects in CML, thereby following the principles of personalized medicine.
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