1
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Tremblay D, Mascarenhas J. Pharmacotherapeutic advances for splenomegaly in myelofibrosis. Expert Opin Pharmacother 2023; 24:577-585. [PMID: 36922391 DOI: 10.1080/14656566.2023.2192350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Myelofibrosis is a hematologic malignancy with a variety of clinical manifestations including splenomegaly, which is present in approximately 80% of newly diagnosed patients. JAK inhibitors are the mainstay of pharmacologic treatment for splenomegaly in myelofibrosis, although spleen size reduction is not universal, and the duration of benefit is only moderately durable. AREAS COVERED We first discuss the pathobiology of splenomegaly in myelofibrosis before detailing approved and novel pharmacotherapies that can reduce spleen size while also highlighting non-pharmacologic approaches. In this review, efficacy of these treatments is measured solely by spleen volume reduction, acknowledging that other outcome measures such as symptom improvement and survival are also critical. EXPERT OPINION Currently, ruxolitinib can be administered to the majority of frontline patients although those with severe thrombocytopenia should receive pacritinib to address spleen burden. Momelotinib may be particularly well suited for patients with significant anemia and novel combination treatments in clinical development may improve the depth and duration of spleen responses. After frontline treatment failure, fedratinib, or pacritinib are commercial options for patients with persistent symptomatic splenomegaly. Novel agents given alone or in combination with a JAK inhibitor are being explored in trials, which may ameliorate splenomegaly and ultimately improve disease progression.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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2
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Passamonti F, Heidel FH, Parikh RC, Ajmera M, Tang D, Nadal JA, Davis KL, Abraham P. Real-world clinical outcomes of patients with myelofibrosis treated with ruxolitinib: a medical record review. Future Oncol 2022; 18:2217-2231. [PMID: 35388710 DOI: 10.2217/fon-2021-1358] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: To assess real-world ruxolitinib treatment patterns and outcomes in patients diagnosed with primary or secondary myelofibrosis. Materials & methods: Patient medical records were reviewed in six countries. Results: Eligible patients (n = 469) had a mean age of 63.5 years, and most were male (66.5%) with primary myelofibrosis (78.5%). Median duration of ruxolitinib treatment was 13.1 months; 40% of patients initiated treatment at the recommended dose. The Kaplan-Meier estimate of median survival from ruxolitinib initiation was 44.4 months (95% CI, 38.8-50.2 months). Approximately one quarter (23%) of patients continued ruxolitinib after progression. Conclusion: These results suggest an unmet need for more effective treatments for patients with myelofibrosis who failed ruxolitinib.
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Affiliation(s)
| | - Florian H Heidel
- Internal Medicine C, University Medicine Greifswald, Greifswald, 17475, Germany
| | - Rohan C Parikh
- Health Economics, RTI Health Solutions, Research Triangle Park, NC 27709, USA
| | - Mayank Ajmera
- Health Economics, RTI Health Solutions, Research Triangle Park, NC 27709, USA
| | - Derek Tang
- Hematology, Bristol Meyers Squibb, Lawrenceville, NJ 08648, USA
| | | | - Keith L Davis
- Health Economics, RTI Health Solutions, Research Triangle Park, NC 27709, USA
| | - Pranav Abraham
- Hematology, Bristol Meyers Squibb, Lawrenceville, NJ 08648, USA
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3
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Appropriate management of polycythaemia vera with cytoreductive drug therapy: European LeukemiaNet 2021 recommendations. Lancet Haematol 2022; 9:e301-e311. [DOI: 10.1016/s2352-3026(22)00046-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 02/06/2023]
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4
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Vachhani P, Verstovsek S, Bose P. Disease Modification in Myelofibrosis: An Elusive Goal? J Clin Oncol 2022; 40:1147-1154. [PMID: 35084934 PMCID: PMC8987221 DOI: 10.1200/jco.21.02246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Pankit Vachhani
- Department of Medicine, Division of Hematology and Oncology, The University of Alabama at Birmingham, Birmingham, AL
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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5
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Chang CS, Chen CW, Chiang IJ, Ku FC, Lee YM, Siddiqui A. A Cross-sectional Study of Patients and Physicians on the Impact of Myeloproliferative Neoplasms on Patient Health: The Landmark Survey From Taiwan. J Patient Exp 2021; 8:23743735211059053. [PMID: 34888413 PMCID: PMC8649420 DOI: 10.1177/23743735211059053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Patients with myeloproliferative neoplasm (MPN), including myelofibrosis,
polycythemia vera, and essential thrombocythemia, experience a pronounced
symptom burden. This study aimed to collect information from physicians and
patients in Taiwan to explore their perceptions regarding MPN, treatment goals,
and satisfaction with disease management. A cross-sectional, online survey was
conducted among patients and physicians from September 2018 to November 2018 in
Taiwan as a subset of the expansion of the Landmark survey. Overall, 50 patients
with MPN and 30 physicians participated in this study. The symptom burden was
low, with the mean number of symptoms experienced being 1.8. The most frequent
symptom per physicians’ perception was fatigue, whereas it is not the most
common symptom from MPN patients’ perspective. Blood count was the key indicator
to determine treatment success from patients’ view, whereas presence of a new
symptom was the key indicator from physicians’ perspective. Concordant with
previous studies, our study revealed a lack of alignment between physician and
patient perceptions relating to treatment goals and disease management.
Nevertheless, the physical, emotional, work/activities and financial impacts on
patients were minimal in Taiwan.
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Parra-Izquierdo I, Melrose AR, Pang J, Lakshmanan HHS, Reitsma SE, Vavilapalli SH, Larson MK, Shatzel JJ, McCarty OJT, Aslan JE. Janus kinase inhibitors ruxolitinib and baricitinib impair glycoprotein-VI mediated platelet function. Platelets 2021; 33:404-415. [PMID: 34097573 PMCID: PMC8648864 DOI: 10.1080/09537104.2021.1934665] [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] [Indexed: 02/09/2023]
Abstract
Several Janus kinase (JAK) inhibitors (jakinibs) have recently been approved to treat inflammatory, autoimmune and hematological conditions. Despite emerging roles for JAKs and downstream signal transducer and activator of transcription (STAT) proteins in platelets, it remains unknown whether jakinibs affect platelet function. Here, we profile platelet biochemical and physiological responses in vitro in the presence of five different clinically relevant jakinibs, including ruxolitinib, upadacitinib, oclacitinib, baricitinib and tofacitinib. Flow cytometry, microscopy and other assays found that potent JAK1/2 inhibitors baricitinib and ruxolitinib reduced platelet adhesion to collagen, as well as platelet aggregation, secretion and integrin αIIbβ3 activation in response to the glycoprotein VI (GPVI) agonist collagen-related peptide (CRP-XL). Western blot analysis demonstrated that jakinibs reduced Akt phosphorylation and activation following GPVI activation, where ruxolitinib and baricitinib prevented DAPP1 phosphorylation. In contrast, jakinibs had no effects on platelet responses to thrombin. Inhibitors of GPVI and JAK signaling also abrogated platelet STAT5 phosphorylation following CRP-XL stimulation. Additional pharmacologic experiments supported roles for STAT5 in platelet secretion, integrin activation and cytoskeletal responses. Together, our results demonstrate that ruxolitinib and baricitinib have inhibitory effects on platelet function in vitro and support roles for JAK/STAT5 pathways in GPVI/ITAM mediated platelet function.
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Affiliation(s)
- Iván Parra-Izquierdo
- Knight Cardiovascular Institute and Division of Cardiology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Alexander R Melrose
- Knight Cardiovascular Institute and Division of Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - Jiaqing Pang
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | | | - Stéphanie E Reitsma
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Sai Hitesh Vavilapalli
- Knight Cardiovascular Institute and Division of Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - Mark K Larson
- Biology Department, Augustana University, Sioux Falls, SD, USA
| | - Joseph J Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.,Division of Hematology and Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.,Division of Hematology and Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Joseph E Aslan
- Knight Cardiovascular Institute and Division of Cardiology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.,Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, Portland, OR, USA
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7
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Yang Y, Luo H, Zheng Y, Zou Z, Niu T, Jia Y, Zhu H, Liu T, Wu Y, Chang H, Ji J, Li J, Pan L. Low-dose ruxolitinib shows effective in treating myelofibrosis. Ann Hematol 2020; 100:135-141. [PMID: 33083863 DOI: 10.1007/s00277-020-04311-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/15/2020] [Indexed: 02/05/2023]
Abstract
The aim of this study was to investigate the effect of low-dose ruxolitinib (daily dose ≤ 10 mg) for the treatment of myelofibrosis (MF). A retrospective analysis was performed on a total of 88 patients with myeloproliferative neoplasm-associated MF (MPN-MF) who were diagnosed and treated in West China Hospital, Sichuan University, China. A total of 44 MPN-MF patients received a low dose of ruxolitinib (daily dose ≤ 10 mg), while another 44 patients received 10-25 mg twice daily. Low-dose ruxolitinib treatment resulted in slow, but gradual spleen response. Compared with baseline, the mean changes in palpable spleen length in the low- and high-dose groups were -26.9 and -49.0% after 12 weeks of treatment, respectively, and -46.7 and -64.1% after 48 weeks of treatment, respectively. In the low dose group, the median myeloproliferative neoplasm symptom assessment form (MPN-SAF) total symptom score (TSS) decreased by 37.8 and 35.9% at the 12 weeks and 48 weeks after treatment, respectively. No statistical difference was observed in MPN-SAF TSS among different dose groups. After 48 weeks of treatment, bone marrow (BM) fibrosis improved in 43.3% (13/30) of evaluated patients and was stable in 56.7% (17/30) patients. In the low-dose treated group, BM fibrosis improved in 50% patients and was stable in remaining 50%. Low-dose ruxolitinib is effective in treating MF.
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Affiliation(s)
- Yunfan Yang
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Hongmei Luo
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Yuhuan Zheng
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Zhongqing Zou
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Ting Niu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Yongqian Jia
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Huanling Zhu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Ting Liu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Yu Wu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Hong Chang
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Jie Ji
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Jian Li
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China
| | - Ling Pan
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 GuoXue Xiang Street, 610041, Chengdu, China.
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8
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Bose P, Verstovsek S. JAK Inhibition for the Treatment of Myelofibrosis: Limitations and Future Perspectives. Hemasphere 2020; 4:e424. [PMID: 32903304 PMCID: PMC7375176 DOI: 10.1097/hs9.0000000000000424] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/26/2020] [Indexed: 12/24/2022] Open
Abstract
The 2011 approval of ruxolitinib ushered in the Janus kinase (JAK) inhibitor era in the treatment of myelofibrosis (MF), and 2019 saw the US approval of fedratinib. The first therapeutic agents approved by regulatory authorities for MF, these drugs attenuate the overactive JAK-signal transducer and activator of transcription (STAT) signaling universally present in these patients, translating into major clinical benefits in terms of spleen shrinkage and symptom improvement. These, in turn, confer a survival advantage on patients with advanced disease, demonstrated in the case of ruxolitinib, for which long-term follow-up data are available. However, JAK inhibitors do not improve cytopenias in most patients, have relatively modest effects on bone marrow fibrosis and driver mutation allele burden, and clinical resistance eventually develops. Furthermore, they do not modify the risk of transformation to blast phase; indeed, their mechanism of action may be more anti-inflammatory than truly disease-modifying. This has spurred interest in rational combinations of JAK inhibitors with other agents that may improve cytopenias and drugs that could potentially modify the natural history of MF. Newer JAK inhibitors that are distinguished from ruxolitinib and fedratinib by their ability to improve anemia (eg, momelotinib) or safety and efficacy in severely thrombocytopenic patients (eg, pacritinib) are in phase 3 clinical trials. There is also interest in developing inhibitors that are highly selective for mutant JAK2, as well as "type II" JAK2 inhibitors. Overall, although current JAK inhibitors have limitations, they will likely continue to form the backbone of MF therapy for the foreseeable future.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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9
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Neoplastic fibrocytes play an essential role in bone marrow fibrosis in Jak2V617F-induced primary myelofibrosis mice. Leukemia 2020; 35:454-467. [PMID: 32472085 PMCID: PMC7862060 DOI: 10.1038/s41375-020-0880-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/07/2020] [Accepted: 05/18/2020] [Indexed: 11/23/2022]
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) characterized by clonal myeloproliferation, progressive bone marrow (BM) fibrosis, splenomegaly, and anemia. BM fibrosis was previously thought to be a reactive phenomenon induced by mesenchymal stromal cells that are stimulated by the overproduction of cytokines such as transforming growth factor (TGF)-β1. However, the involvement of neoplastic fibrocytes in BM fibrosis was recently reported. In this study, we showed that the vast majority of collagen- and fibronectin-producing cells in the BM and spleens of Jak2V617F-induced myelofibrosis (MF) mice were fibrocytes derived from neoplastic hematopoietic cells. Neoplastic monocyte depletion eliminated collagen- and fibronectin-producing fibrocytes in BM and spleen, and ameliorated most characteristic MF features in Jak2V617F transgenic mice, including BM fibrosis, anemia, and splenomegaly, while had little effect on the elevated numbers of megakaryocytes and stem cells in BM, and leukothrombocytosis in peripheral blood. TGF-β1, which was produced by hematopoietic cells including fibrocytes, promoted the differentiation of neoplastic monocytes to fibrocytes, and elevated plasma TGF-β1 levels were normalized by monocyte depletion. Collectively, our data suggest that neoplastic fibrocytes are the major contributor to BM fibrosis in PMF, and TGF-β1 is required for their differentiation.
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10
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Iurlo A, Cattaneo D, Bucelli C. Management of Myelofibrosis: from Diagnosis to New Target Therapies. Curr Treat Options Oncol 2020; 21:46. [DOI: 10.1007/s11864-020-00734-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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11
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Abstract
Over the last decade, the Janus kinase1/2 (JAK1/2) inhibitor ruxolitinib has emerged as a cornerstone of myelofibrosis (MF) management. Ruxolitinib improves splenomegaly and symptoms regardless of driver mutation status, and confers a survival advantage in patients with intermediate-2/high risk MF. However, cytopenias remain problematic, and evidence for a robust anti-clonal effect is lacking. Furthermore, the median duration of spleen response to ruxolitinib in clinical trials is approximately 3 years, and ruxolitinib does not appear to affect the risk of leukemic transformation. There is no therapy approved specifically for patients whose disease 'progresses' on ruxolitinib, defining which remains challenging. The recent regulatory approval of the JAK2 inihibitor fedratinib partially fulfills this unmet need, but much remains to be done. Other JAK inhibitors and a plethora of novel agents are being studied in the ruxolitinib 'failure' setting, as well as 'add-on' therapies to ruxolitinib in patients having a 'sub-optimal' response.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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Breccia M, Baratè C, Benevolo G, Bonifacio M, Elli EM, Guglielmelli P, Maffioli M, Malato A, Mendicino F, Palumbo GA, Pugliese N, Rossi E, Rumi E, Sant'Antonio E, Ricco A, Tiribelli M, Palandri F. Tracing the decision-making process for myelofibrosis: diagnosis, stratification, and management of ruxolitinib therapy in real-word practice. Ann Hematol 2020; 99:65-72. [PMID: 31832751 PMCID: PMC6944647 DOI: 10.1007/s00277-019-03847-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
Abstract
The management of patients with myelofibrosis (MF) has dramatically changed since the introduction of ruxolitinib as a tailored treatment strategy. However, the perceptions about the use of this drug in clinical practice remain, at times, a matter of discussion. We conducted a survey about the diagnostic evaluation, prognostic assessment, and management of ruxolitinib in real-life clinical practice in 18 Italian hematology centers. At diagnosis, most hematologists do not use genetically or molecularly inspired score systems to assess prognosis, mainly due to scarce availability of next-generation sequencing (NGS) methodology, with NGS conversely reserved only for a subset of lower-risk MF patients with the aim of possibly improving the treatment strategy. Some common points in the management of ruxolitinib were 1) clinical triggers for ruxolitinib therapy, regardless of risk category; 2) evaluation of infectious risk before the starting of the drug; and 3) schedule of monitoring during the first 12 weeks with the need, in some instances, of supportive treatment. Further development of international recommendations and insights will allow the achievement of common criteria for the management of ruxolitinib in MF, before and after treatment, and for the definition of response and failure.
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Affiliation(s)
- Massimo Breccia
- Hematology, Department of Precision and Translational Medicine, Policlinico Umberto 1, Sapienza University, Rome, Italy.
| | - Claudia Baratè
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Giulia Benevolo
- Hematology, Città della Salute e della Scienza, Turin, Italy
| | | | - Elena Maria Elli
- Hematology Division and Bone Marrow Transplant Unit, ASST Monza, Ospedale San Gerardo, Monza, Italy
| | - Paola Guglielmelli
- Center of Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence, Florence, Italy
| | | | - Alessandra Malato
- Division of Hematology and Bone Marrow Transplant, Villa Sofia-Cervello Hospital, 90146, Palermo, Italy
| | - Francesco Mendicino
- Hematology Unit, Department of Hemato-Oncology, Ospedale Annunziata, Via San Martino, snc -, 87100, Cosenza, Italy
| | - Giuseppe Alberto Palumbo
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Novella Pugliese
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Elena Rossi
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Elisa Rumi
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Emanuela Sant'Antonio
- Department of Oncology, Division of Hematology, Azienda USL Toscana Nord Ovest, Lucca, Italy
- Medical Genetics, University of Siena, Siena, Italy
| | - Alessandra Ricco
- Department of Emergency and Organ Transplantation (DETO), Hematology Section, University of Bari, Bari, Italy
| | - Mario Tiribelli
- Division of Hematology and Bone Marrow Transplantation, Department of Medical Area, University of Udine, Udine, Italy
| | - Francesca Palandri
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
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13
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Barraco D, Maffioli M, Passamonti F. Standard care and investigational drugs in the treatment of myelofibrosis. Drugs Context 2019; 8:212603. [PMID: 31645880 PMCID: PMC6788389 DOI: 10.7573/dic.212603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 01/07/2023] Open
Abstract
Myelofibrosis (MF) is a heterogeneous disorder characterized by splenomegaly, constitutional symptoms, ineffective hematopoiesis, and an increased risk of leukemic transformation. The ongoing research in understanding the pathophysiology of the disease has allowed for the development of targeted drugs optimizing patient management. Furthermore, disease prognostication has significantly improved. Current therapeutic interventions are only partially effective with only allogeneic stem cell transplant potentially curative. Ruxolitinib is the only approved therapy for MF by the US Food and Drug Administration. However, despite efficacy in reducing splenomegaly and controlling symptomatology, it is not associated with consistent molecular or pathologic responses. Drug discontinuation is associated with a dismal outcome. The therapeutic landscape in MF has significantly improved, and emerging drugs with different target pathways, alone or in combination with ruxolitinib, seem promising.
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Affiliation(s)
- Daniela Barraco
- Hematology, Department of Specialistic Medicine, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Margherita Maffioli
- Hematology, Department of Specialistic Medicine, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy
| | - Francesco Passamonti
- Hematology, Department of Specialistic Medicine, Ospedale di Circolo, ASST Sette Laghi, Varese, Italy.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
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14
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The role of allogeneic stem-cell transplant in myelofibrosis in the era of JAK inhibitors: a case-based review. Bone Marrow Transplant 2019; 55:708-716. [PMID: 31534197 PMCID: PMC7113188 DOI: 10.1038/s41409-019-0683-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 01/11/2023]
Abstract
Allogeneic hematopoietic stem-cell transplantation (HSCT) is, at present, the only potentially curative therapy for myelofibrosis (MF). Despite many improvements, outcomes of HSCT are still burdened by substantial morbidity and high transplant-related mortality. Allogeneic transplant is generally considered in intermediate-2 and high-risk patients aged <70 years, but the optimal selection of patients and timing of the procedure remains under debate, as does as the role of JAK inhibitors in candidates for HSCT. Starting from a real-life clinical case scenario, herein we examine some of the crucial issues of HSCT for MF in light of recent refinements on MF risk stratification, data on the use of ruxolitinib before and after transplant and findings on the impact of different conditioning regimens and donor selection.
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15
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Breccia M, Luciano L, Pugliese N, Rossi E, Tiribelli M, Scalzulli E, Bonifacio M, Martino B, Latagliata R, Benevolo G, Caocci G, Binotto G, Martinelli V, Cavo M, Pane F, De Stefano V, Foà R, Palandri F. Efficacy and safety of ruxolitinib and hydroxyurea combination in patients with hyperproliferative myelofibrosis. Ann Hematol 2019; 98:1933-1936. [PMID: 31201513 DOI: 10.1007/s00277-019-03727-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 06/03/2019] [Indexed: 11/25/2022]
Abstract
Ruxolitinib is the only commercially available JAK1/2 inhibitor approved for the treatment of myelofibrosis-related splenomegaly and symptoms. During treatment, as rare conditions, leukocytosis and/or thrombocytosis could develop and the management of these situations is not well established. We report here 53 myelofibrosis patients that received a combination of hydroxyurea and ruxolitinib because of uncontrolled myeloproliferation. Both drugs were administered outside clinical trials. At 48 weeks, a significant reduction in leucocyte and platelet counts was observed (p = 0.02 and p = 0.04, respectively). Additionally, the spleen volume decreased from a median value of 10 cm below the left costal margin (range, 0-10) to 6 cm (range, 0-15). The rate of spleen response increased from 14% at the start of the combination to 45% after 48 weeks. The safety profile of the combination was consistent with that observed with ruxolitinib single agent. These data require further confirmation in large cohorts of patients prospectively assessed.
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Affiliation(s)
- Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy.
| | | | | | - Elena Rossi
- Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
- Institute of Hematology, Catholic University, Rome, Italy
| | - Mario Tiribelli
- Division of Hematology and BMT, Department of Medical Area, University of Udine, Udine, Italy
| | - Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | | | - Bruno Martino
- Division of Hematology, Azienda Ospedaliera 'Bianchi Melacrino Morelli', Reggio Calabria, Italy
| | - Roberto Latagliata
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Giulia Benevolo
- Division of Hematology, Città della Salute e della Scienza Hospital, Torino, Italy
| | - Giovanni Caocci
- Department of Medical Sciences and Public Health, Hematology and Transplant Center, Businco Hospital, University of Cagliari, Cagliari, Italy
| | - Gianni Binotto
- Unit of Hematology and Clinical Immunology, University of Padova, Padova, Italy
| | | | - Michele Cavo
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Valerio De Stefano
- Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
- Institute of Hematology, Catholic University, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Francesca Palandri
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
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16
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MF management. Hemasphere 2019; 3:HemaSphere-2019-0024. [PMID: 35309812 PMCID: PMC8925717 DOI: 10.1097/hs9.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 11/25/2022] Open
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17
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Pu JJ, Poulose J, Malysz J, Zhu J, Fanburg-Smith JC, Claxton DF, Bayerl MG. Impact of ruxolitinib on myelofibrosis patients post allogeneic stem cell transplant-a pilot study. Br J Haematol 2019; 186:e130-e133. [PMID: 31115038 DOI: 10.1111/bjh.15967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Jeffrey J Pu
- Penn State Hershey Cancer Institute, Penn State University College of Medicine, Hershey, PA, USA.,Departments of Medicine, Pathology, and Pharmacology, Upstate Cancer Center, SUNY Upstate Medical University, Syracuse, NY, USA.,Syracuse VA Medical Center, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Joyson Poulose
- Penn State Hershey Cancer Institute, Penn State University College of Medicine, Hershey, PA, USA
| | - Jozef Malysz
- Penn State Hershey Cancer Institute, Penn State University College of Medicine, Hershey, PA, USA
| | - Junjia Zhu
- Penn State Hershey Cancer Institute, Penn State University College of Medicine, Hershey, PA, USA
| | - Julie C Fanburg-Smith
- Penn State Hershey Cancer Institute, Penn State University College of Medicine, Hershey, PA, USA
| | - David F Claxton
- Penn State Hershey Cancer Institute, Penn State University College of Medicine, Hershey, PA, USA
| | - Michael G Bayerl
- Penn State Hershey Cancer Institute, Penn State University College of Medicine, Hershey, PA, USA
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18
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SOHO State of the Art Updates and Next Questions: Myelofibrosis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:191-199. [PMID: 30987952 DOI: 10.1016/j.clml.2019.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/12/2019] [Indexed: 01/09/2023]
Abstract
The discovery of a mutation in the Janus Kinase 2 gene in 2005 spurred significant progress in the field of myeloproliferative neoplasms. A comprehensive description of genomic factors at play in the malignant clone in myeloproliferative neoplasms, particularly myelofibrosis (MF), have recently led to more precise, personalized prognostic tools. Despite this, understanding of the disease pathogenesis remains relatively limited. We continue to lack a detailed description of the interaction between the hematopoietic stem cell clone, abnormal bone marrow niche cells, and circulating signaling molecules and an understanding of how they cooperate to promote cell proliferation, fibrogenesis, and extramedullary hematopoiesis. Despite our knowledge gaps, recent research in MF has led to promising clinical translation. In this article, we summarize recent insights into MF pathophysiology, progress in the development of novel therapeutics, and opportunities for further advancement of the field.
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19
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Xiao ZJ. [How I treat primary myelofibrosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:179-181. [PMID: 30929381 PMCID: PMC7342540 DOI: 10.3760/cma.j.issn.0253-2727.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Indexed: 11/21/2022]
Affiliation(s)
- Z J Xiao
- Blood Diseases Hospital and Institute of Hematology, CAMS & PUMC, Tianjin 300020, China
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20
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Impact of comorbidities and body mass index in patients with myelofibrosis treated with ruxolitinib. Ann Hematol 2018; 98:889-896. [DOI: 10.1007/s00277-018-3569-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022]
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21
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Pacilli A, Rotunno G, Mannarelli C, Fanelli T, Pancrazzi A, Contini E, Mannelli F, Gesullo F, Bartalucci N, Fattori GC, Paoli C, Vannucchi AM, Guglielmelli P. Mutation landscape in patients with myelofibrosis receiving ruxolitinib or hydroxyurea. Blood Cancer J 2018; 8:122. [PMID: 30467377 PMCID: PMC6250726 DOI: 10.1038/s41408-018-0152-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/27/2018] [Accepted: 10/15/2018] [Indexed: 12/12/2022] Open
Abstract
Refractoriness to ruxolitinib in patients with myelofibrosis (MF) was associated with clonal evolution; however, whether genetic instability is promoted by ruxolitinib remains unsettled. We evaluated the mutation landscape in 71 MF patients receiving ruxolitinib (n = 46) and hydroxyurea (n = 25) and correlated with response. A spleen volume response (SVR) was obtained in 57% and 12%, respectively. Highly heterogenous patterns of mutation acquisition/loss and/or changes of variant allele frequency (VAF) were observed in the 2 patient groups without remarkable differences. In patients receiving ruxolitinib, driver mutation type and high-molecular risk profile (HMR) at baseline did not impact on response rate, while HMR and sole ASXL1 mutations predicted for SVR loss at 3 years. In patients with SVR, a decrease of ≥ 20% of JAK2V617F VAF predicted for SVR duration. VAF increase of non-driver mutations and clonal progression at follow-up correlated with SVR loss and treatment discontinuation, and clonal progression also predicted for shorter survival. These data indicate that (i) ruxolitinib does not appreciably promote clonal evolution compared with hydroxyurea, (ii) VAF increase of pre-existing and/or (ii) acquisition of new mutations while on treatment correlated with higher rate of discontinuation and/or death, and (iv) reduction of JAK2V617F VAF associated with SVR duration.
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Affiliation(s)
- Annalisa Pacilli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | - Giada Rotunno
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | - Carmela Mannarelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | | | - Alessandro Pancrazzi
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | - Elisa Contini
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | - Francesco Mannelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | - Francesca Gesullo
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | - Niccolò Bartalucci
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | | | - Chiara Paoli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
| | - Alessandro M Vannucchi
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy.
| | - Paola Guglielmelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie Mieloproliferative, Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, Italy
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22
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Talpaz M, Erickson-Viitanen S, Hou K, Hamburg S, Baer MR. Evaluation of an alternative ruxolitinib dosing regimen in patients with myelofibrosis: an open-label phase 2 study. J Hematol Oncol 2018; 11:101. [PMID: 30086777 PMCID: PMC6081850 DOI: 10.1186/s13045-018-0642-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/18/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Ruxolitinib improves splenomegaly and symptoms in patients with intermediate-2 or high-risk myelofibrosis; however, nearly half develop grade 3/4 anemia and/or thrombocytopenia, necessitating dose reductions and/or transfusions. We report findings from an open-label phase 2 study exploring a dose-escalation strategy aimed at preserving clinical benefit while reducing hematological adverse events early in ruxolitinib treatment. METHODS Patients with myelofibrosis received ruxolitinib 10 mg twice daily (BID), with incremental increases of 5 mg BID at weeks 12 and 18 for lack of efficacy (maximum, 20 mg BID). Symptom severity was measured using the Myelofibrosis Symptom Assessment Form Total Symptom Score (MFSAF TSS). RESULTS Forty-five patients were enrolled, 68.9% of whom had a Dynamic International Prognostic Scoring System score of 1 to 2 (i.e., intermediate-1 disease risk). Median percentage change in spleen volume from baseline to week 24 was - 17.3% (≥ 10% reduction achieved by 26 patients [57.8%]), with a clear dose response. Median percentage change in MFSAF TSS from baseline at week 24 was - 45.6%, also with a dose response. The most frequent treatment-emergent adverse events were anemia (26.7%), fatigue (22.2%), and arthralgias (20.0%). Grade 3/4 anemia (20.0%) and dose decreases due to anemia (11.1%) or thrombocytopenia (6.7%) were infrequent. CONCLUSIONS A dose-escalation approach may mitigate worsening anemia during early ruxolitinib therapy in some patients with myelofibrosis. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT01445769 . Registered September 23, 2011.
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Affiliation(s)
| | | | - Kevin Hou
- Incyte Corporation, Wilmington, DE, USA
| | - Solomon Hamburg
- Tower Hematology Oncology Medical Group, Beverly Hills, CA, USA
| | - Maria R Baer
- University of Maryland, Greenebaum Comprehensive Cancer Center, 22 S. Greene St, Baltimore, MD, 21201, USA.
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23
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Krauth MT, Burgstaller S, Buxhofer-Ausch V, Gastl G, Geissler K, Keil F, Krippl P, Melchardt T, Petzer A, Rumpold H, Sliwa T, Wöhrer S, Wölfler A, Gisslinger H. Ruxolitinib therapy for myelofibrosis in Austria : Consensus on therapy management. Wien Klin Wochenschr 2018; 130:495-504. [PMID: 30043249 PMCID: PMC6132876 DOI: 10.1007/s00508-018-1365-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/04/2018] [Indexed: 12/19/2022]
Abstract
The oral Janus associated kinase (JAK1/2) inhibitor ruxolitinib has been available for treatment of patients with intermediate or high-risk myelofibrosis in Europe since 2012. Since its introduction, the expertise of prescribing doctors with respect to ruxolitinib function, efficacy and adverse effects has consistently been augmented, resulting in therapy modalities that are better tailored to individual patients as well as in increased safety of the treatment. The present consensus on ruxolitinib therapy management has been elaborated by Austrian experts in myeloproliferative neoplasms in line with international treatment guidelines. Our recommendations aim to contribute to an improved management of patients with myelofibrosis treated with ruxolitinib.
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Affiliation(s)
- Maria-Theresa Krauth
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria.
| | - Sonja Burgstaller
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I, Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz-Elisabethinen, Linz, Austria
| | - Günther Gastl
- Department of Internal Medicine V, Division Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Geissler
- Fifth Medical Department, Hospital Hietzing, Vienna, Austria
| | - Felix Keil
- Third Medical Department, Hanusch Hospital, Vienna, Austria
| | - Peter Krippl
- Department of Internal Medicine, LKH Fürstenfeld, Krankenhausverbund Feldbach, Fürstenfeld, Austria
| | - Thomas Melchardt
- Third Medical Department, Division Hematology and Medical Oncology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Andreas Petzer
- Department of Internal Medicine I, Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz-Elisabethinen, Linz, Austria
| | - Holger Rumpold
- Internal Medicine II, Medical Oncology, Hematology, Gastroenterology and Rheumatology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Thamer Sliwa
- Third Medical Department, Hanusch Hospital, Vienna, Austria
| | - Stefan Wöhrer
- Permedio Center for Personalized Medicine and Sanatorium Hera Vienna, Vienna, Austria
| | - Albert Wölfler
- Division of Hematology, Medical University of Graz, Graz, Austria
| | - Heinz Gisslinger
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
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24
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Finazzi G, De Stefano V, Barbui T. Splanchnic vein thrombosis in myeloproliferative neoplasms: treatment algorithm 2018. Blood Cancer J 2018; 8:64. [PMID: 29946154 PMCID: PMC6018786 DOI: 10.1038/s41408-018-0100-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
Myeloproliferative neoplasms (MPNs) are a leading cause of splanchnic vein thrombosis (SVT). SVT is observed in all MPNs and frequently affects young patients. Therapy should be addressed to three main goals: preventing thrombosis recurrence, managing the underlying MPN, and supporting liver dysfunction. Life-long oral anticoagulation with vitamin K antagonists is the cornerstone of the antithrombotic treatment. However, recurrences of SVT or other thrombosis may occur in 15-20% of patients. Direct oral anticoagulants can represent an alternative and preliminary data encourage comparative studies. Survival of patients with SVT in MPN is primarily influenced by the natural history of the underlying neoplasms, rather than the SVT event. An aggressive management is recommended and a treatment algorithm based on the different MPN subtypes is proposed. Hydroxyurea is the cytoreductive drug of choice in polycythemia vera and essential thrombocythemia, whereas ruxolitinib is indicated in intermediate and high-risk patients with myelofibrosis and in PV patients resistant or intolerant to hydroxyurea. The management of SVT in MPNs requires a multidisciplinary approach that may include a hematologist, a gastroenterologist, an interventional radiologist, and a surgeon. In the case of clinical deterioration despite pharmacological therapy, patients with SVT should be considered for invasive procedures or liver transplantation.
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Affiliation(s)
- Guido Finazzi
- USC Hematology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Valerio De Stefano
- Institute of Hematology, Catholic University, Roma, Italy.,IRCCS Policlinico Gemelli Foundation, Roma, Italy
| | - Tiziano Barbui
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy.
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25
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Devos T, Selleslag D, Zachée P, Benghiat FS. Recommendations on the use of ruxolitinib for the treatment of myelofibrosis. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2018; 23:194-200. [PMID: 29022420 DOI: 10.1080/10245332.2017.1385192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Myelofibrosis (MF) is a severe disease, with decreased life expectancy and heavy symptom burden. Ruxolitinib is the only approved pharmacotherapy for the treatment of MF patients. In Belgium, ruxolitinib is only reimbursed for MF patients with splenomegaly for whom the disease is categorized as intermediate-2 or high risk. The improvement of symptoms without spleen volume reduction is not considered sufficient to continue treatment. The aim of this manuscript is to provide guidance for the safe and effective administration of ruxolitinib, considering the particularities of the Belgian reimbursement criteria. METHODS Our recommendations are based on a consensus reached during two meetings, where available data and observations derived from clinical experience were discussed. RESULTS AND DISCUSSION We recommend changing the current Belgian reimbursement conditions to include the evaluation of disease-related symptoms along with splenomegaly to decide whether ruxolitinib treatment should be continued or not. Indeed, the decrease in disease-related symptoms seems to be an equally important parameter as the decrease in splenic volume in the evaluation of the response to ruxolitinib. We also advocate for the treatment with ruxolitinib of MF patients in lower-risk categories with severe disease-related symptoms, as this drug could greatly improve their quality of life. Optimization of the ruxolitinib dose is recommended to avoid an unnecessary decrease in platelet count or hemoglobin that may jeopardize treatment continuation. CONCLUSION With the aim to optimize the treatment of MF patients, the Belgian regulation for ruxolitinib should be revised in terms of reimbursement criteria, dose titration, stopping rules, and patient follow-up.
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Affiliation(s)
- Timothy Devos
- a Department of Hematology , University Hospitals Leuven , Leuven , Belgium.,b Laboratory of Experimental Transplantation, Department of Microbiology and Immunology , KU Leuven , Leuven , Belgium
| | - Dominik Selleslag
- c Department of Hematology , Algemeen Ziekenhuis Sint-Jan , Bruges , Belgium
| | - Pierre Zachée
- d Department of Hematology , Hospital Network Antwerp , Antwerp , Belgium
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26
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The role of JAK2 inhibitors in MPNs 7 years after approval. Blood 2018; 131:2426-2435. [PMID: 29650801 DOI: 10.1182/blood-2018-01-791491] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/07/2018] [Indexed: 12/14/2022] Open
Abstract
Myeloproliferative neoplasms (MPNs) include essential thrombocythemia, polycythemia vera (PV), and primary myelofibrosis (MF). Phenotype-driver mutations of JAK2, CALR, and MPL genes are present in MPNs and can be variably combined with additional mutations. Driver mutations entail a constitutive activation of the JAK2/STAT pathway, the key signaling cascade in MPNs. Among JAK2 inhibitors (JAKis), ruxolitinib (RUX) has been approved for the treatment of intermediate and high-risk MF and for PV inadequately controlled by or intolerant of hydroxyurea. Other JAKis, such as fedratinib and pacritinib, proved to be useful in MF. The primary end points in MF trials were spleen volume response (SVR) and symptom response, whereas in PV trials they were hematocrit control with or without spleen response. In advanced MF, RUX achieved a long lasting SVR of >35% in ∼60% of patients, establishing a new benchmark for MF treatment. RUX efficacy in early MF is also remarkable and toxicity is mild. In PV, RUX achieved hematocrit control in ∼60% of cases and SVR in 40%. Symptom relief was evident in both conditions. In the long-term, however, many MF patients lose their SVR. Indeed, the definition of RUX failure and the design of new trials in this setting are unmet needs. Decrease of hemoglobin/platelet levels and increased infection rates are the most common side effects of RUX, and nonmelanoma skin tumors need to be monitored while on treatment. In conclusion, the introduction of JAKis raises the bar of treatment goals in MF and PV.
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27
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Hehlmann R. Advancing a field by building consortia: The example of the European LeukemiaNet. Cancer 2018; 124:1100-1104. [PMID: 29451688 DOI: 10.1002/cncr.31199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Rüdiger Hehlmann
- European LeukemiaNet Foundation, Weinheim, Germany
- Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany
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28
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Philadelphia chromosome-negative classical myeloproliferative neoplasms: revised management recommendations from European LeukemiaNet. Leukemia 2018. [PMID: 29515238 DOI: 10.1038/s41375-018-0077-1] [Citation(s) in RCA: 353] [Impact Index Per Article: 58.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This document updates the recommendations on the management of Philadelphia chromosome-negative myeloproliferative neoplasms (Ph-neg MPNs) published in 2011 by the European LeukemiaNet (ELN) consortium. Recommendations were produced by multiple-step formalized procedures of group discussion. A critical appraisal of evidence by using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology was performed in the areas where at least one randomized clinical trial was published. Seven randomized controlled trials provided the evidence base; earlier phase trials also informed recommendation development. Key differences from the 2011 diagnostic recommendations included: lower threshold values for hemoglobin and hematocrit and bone marrow examination for diagnosis of polycythemia vera (PV), according to the revised WHO criteria; the search for complementary clonal markers, such as ASXL1, EZH2, IDH1/IDH2, and SRSF2 for the diagnosis of myelofibrosis (MF) in patients who test negative for JAK2V617, CALR or MPL driver mutations. Regarding key differences of therapy recommendations, both recombinant interferon alpha and the JAK1/JAK2 inhibitor ruxolitinib are recommended as second-line therapies for PV patients who are intolerant or have inadequate response to hydroxyurea. Ruxolitinib is recommended as first-line approach for MF-associated splenomegaly in patients with intermediate-2 or high-risk disease; in case of intermediate-1 disease, ruxolitinib is recommended in highly symptomatic splenomegaly. Allogeneic stem cell transplantation is recommended for transplant-eligible MF patients with high or intermediate-2 risk score. Allogeneic stem cell transplantation is also recommended for transplant-eligible MF patients with intermediate-1 risk score who present with either refractory, transfusion-dependent anemia, blasts in peripheral blood > 2%, adverse cytogenetics, or high-risk mutations. In these situations, the transplant procedure should be performed in a controlled setting.
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29
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Bose P, Gotlib J, Harrison CN, Verstovsek S. SOHO State-of-the-Art Update and Next Questions: MPN. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2018; 18:1-12. [PMID: 29277359 PMCID: PMC5915302 DOI: 10.1016/j.clml.2017.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/27/2017] [Indexed: 12/28/2022]
Abstract
The discovery of the activating Janus kinase (JAK)2V617F mutation in 2005 in most patients with the classic Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) spurred intense interest in research into these disorders, culminating in the identification of activating mutations in MPL in 2006 and indels in the gene encoding calreticulin (CALR) in 2013, thus providing additional mechanistic explanations for the universal activation of JAK-signal transducer and activator of transcription (JAK-STAT) observed in these conditions, and the success of the JAK1/2 inhibitor ruxolitinib, which first received regulatory approval in 2011. The field has continued to advance rapidly since then, and the past 2 years have witnessed important changes to the classification of MPN and diagnostic criteria for polycythemia vera (PV), novel insights into the mechanisms of bone marrow fibrosis in primary myelofibrosis (PMF), increasing appreciation of the biologic differences between essential thrombocythemia (ET), prefibrotic and overt PMF, and between primary and post-PV/ET myelofibrosis (MF). Additionally, the mechanisms through which mutant CALR drives JAK-STAT pathway activation and oncogenic transformation are now better understood. Although mastocytosis is no longer included under the broad heading of MPN in the 2016 revision to the World Health Organization classification, an important milestone in mastocytosis research was reached in 2017 with the regulatory approval of midostaurin for patients with advanced systemic mastocytosis (AdvSM). In this article, we review the major recent developments in the areas of PV, ET, and MF, and also briefly summarize the literature on midostaurin and other KIT inhibitors for patients with AdvSM.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX.
| | - Jason Gotlib
- Department of Medicine - Hematology, Stanford University, Palo Alto, CA
| | | | - Srdan Verstovsek
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX
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Griesshammer M, Sadjadian P. The BCR-ABL1-negative myeloproliferative neoplasms: a review of JAK inhibitors in the therapeutic armamentarium. Expert Opin Pharmacother 2017; 18:1929-1938. [PMID: 29134817 DOI: 10.1080/14656566.2017.1404574] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The classical BCR-ABL1-negative myeloproliferative neoplasms (MPN) include primary myelofibrosis (PMF), polycythemia vera (PV) and essential thrombocythemia (ET). They are characterized by stem cell-derived clonal proliferation, harbor Janus kinase 2 (JAK2), or calreticulin (CALR), or myeloproliferative leukemia virus oncogene (MPL) driver mutations and exert an over activated JAK-signal transducer and activator of transcription (STAT) pathway. Therefore JAK inhibiting strategies have been successfully investigated in MPN clinical trials. Areas covered: The present review aims to provide a concise overview of the current and future role of JAK inhibitors in the therapeutic armamentarium of MPN. Expert opinion: The JAK1/JAK2 inhibitor ruxolitinib has clearly enriched the therapeutic armamentarium of MPN and is now licenced for more than five years in MF and over three years as second line in PV. Momelotinib, although of limited activity in MPN trials, demonstrated unique property of improving MF associated anemia. Less myelosuppressive or more selective JAK inhibitors like pacritinib, NS-01872 or Itacitinib are new promising agents tested in MF. JAK inhibition has become a cornerstone of MPN therapy and future efforts focus on ruxolitinib-based combinations and new JAK inhibitors.
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Affiliation(s)
- Martin Griesshammer
- a University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care , Johannes Wesling Medical Center Minden, UKRUB, University of Bochum , Minden , Germany
| | - Parvis Sadjadian
- a University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care , Johannes Wesling Medical Center Minden, UKRUB, University of Bochum , Minden , Germany
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Ellis MH, Koren-Michowitz M, Lavi N, Vannucchi AM, Mesa R, Harrison CN. Ruxolitinib for the management of myelofibrosis: Results of an international physician survey. Leuk Res 2017; 61:6-9. [PMID: 28843161 DOI: 10.1016/j.leukres.2017.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/21/2017] [Accepted: 08/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ruxolitinib is established as treatment for symptomatic myeloproliferative neoplasm (MPN)-associated myelofibrosis. The strict inclusion and exclusion criteria and dose modification rules that applied to the COMFORTI and II studies that led to the licensing of ruxolitinib are not always applicable to routine clinical practice. Thus physicians now face decisions regarding ruxolitinib use that were not addressed in these pivotal trials. METHODS We performed an online survey of hematologists practicing in Europe, Israel, the United Kingdom and the United States. Demographic details regarding the physicians and their practice as relates to MPNs were collected. Management decisions pertaining to the use of ruxolitinib were obtained regarding 10 clinical scenarios relating to anemia, thrombocytopenia, frailty, infection and lack or loss of response to ruxolitnib in MF patients. RESULTS 140 physicians responded to the survey. There were marked differences regarding their decisions for ruxolitinib administration in MF patients with or developing anemia or thrombocytopenia. Similarly there was little consensus regarding management of patients refractory or losing a response to ruxolitinib. There were differences between "MPN-focused" and "non-MPN-focused" physicians in certain areas. CONCLUSION Physician practices regarding management of MF patients experiencing ruxolitinib-related toxicities or in whom response to the drug is lost was variable. This was true of "MPN-focused" and "non-MPN-focused" physicians in certain cases. Physician education and experience in using ruxolitinib may improve patient management.
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Affiliation(s)
- Martin H Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Maya Koren-Michowitz
- Department of Hematology, Asaf HaRofeh Medical Center, Tzrifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Lavi
- Rambam Medical Center, Haifa, Israel; Bruce Rappoport Faculty of Medicine, Technion, Haifa, Israel
| | - Alessandro M Vannucchi
- Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Ruben Mesa
- Department of Hematology, Mayo Clinic Scottsdale, AZ, USA
| | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
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Bose P, Verstovsek S. JAK2 inhibitors for myeloproliferative neoplasms: what is next? Blood 2017; 130:115-125. [PMID: 28500170 PMCID: PMC5510786 DOI: 10.1182/blood-2017-04-742288] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/06/2017] [Indexed: 12/11/2022] Open
Abstract
Since its approval in 2011, the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib has evolved to become the centerpiece of therapy for myelofibrosis (MF), and its use in patients with hydroxyurea resistant or intolerant polycythemia vera (PV) is steadily increasing. Several other JAK2 inhibitors have entered clinical testing, but none have been approved and many have been discontinued. Importantly, the activity of these agents is not restricted to patients with JAK2 V617F or exon 12 mutations. Although JAK2 inhibitors provide substantial clinical benefit, their disease-modifying activity is limited, and rational combinations with other targeted agents are needed, particularly in MF, in which survival is short. Many such combinations are being explored, as are other novel agents, some of which could successfully be combined with JAK2 inhibitors in the future. In addition, new JAK2 inhibitors with the potential for less myelosuppression continue to be investigated. Given the proven safety and efficacy of ruxolitinib, it is likely that ruxolitinib-based combinations will be a major way forward in drug development for MF. If approved, less myelosuppressive JAK2 inhibitors such as pacritinib or NS-018 could prove to be very useful additions to the therapeutic armamentarium in MF. In PV, inhibitors of histone deacetylases and human double minute 2 have activity, but their role, if any, in the future treatment algorithm is uncertain, given the availability of ruxolitinib and renewed interest in interferons. Ruxolitinib is in late-phase clinical trials in essential thrombocythemia, in which it could fill an important void for patients with troublesome symptoms.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
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Saeed I, McLornan D, Harrison CN. Managing side effects of JAK inhibitors for myelofibrosis in clinical practice. Expert Rev Hematol 2017; 10:617-625. [PMID: 28571503 DOI: 10.1080/17474086.2017.1337507] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Myelofibrosis (MF) is characterized by bone marrow fibrosis, abnormalities in peripheral counts, extramedullary hematopoiesis, splenomegaly and an increased risk of transformation to acute myeloid leukaemia. The disease course is often heterogeneous and management can range from observation alone through to allogeneic stem cell transplantation. As of 2017, the only approved medication for MF remains the JAK Inhibitor (JAKi), ruxolitinib (Novartis Pharmaceuticals, Basel, Switzerland; Incyte, Wilmington, Detroit, USA) although several others have reached advanced stages of clinical trials. Areas covered: In this review, we focus on the management of both common and uncommon side effects arising from the use of currently approved and clinical trial JAKi. Most of the discussion concerns ruxolitinib although we also cover both pacritinib (CTI BioPharma) and momelotinib (Gilead Sciences, Foster City, California) which have been in recent large, multinational phase III trials. The various approaches to management of JAKi-related side effects are discussed - with particular emphasis to anaemia, thrombocytopaenia and infection risk. Expert commentary: JAK inhibitors are effective in many individuals with MF and have revolutionized the current treatment paradigm. The side effect profile, in the most, is predictable and manageable with high degrees of clinical surveillance and dose modifications.
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Affiliation(s)
- Iram Saeed
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK
| | - Donal McLornan
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK.,b Department of Haematology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - Claire N Harrison
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK
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Palandri F, Tiribelli M, Benevolo G, Tieghi A, Cavazzini F, Breccia M, Bergamaschi M, Sgherza N, Polverelli N, Crugnola M, Isidori A, Binotto G, Heidel FH, Buccisano F, Martino B, Latagliata R, Spinsanti M, Kallenberg L, Palumbo GA, Abruzzese E, Scaffidi L, Cuneo A, Cavo M, Vianelli N, Bonifacio M. Efficacy and safety of ruxolitinib in intermediate-1 IPSS risk myelofibrosis patients: Results from an independent study. Hematol Oncol 2017; 36:285-290. [DOI: 10.1002/hon.2429] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Francesca Palandri
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology 'L. and A. Seràgnoli'; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
| | - Mario Tiribelli
- Division of Hematology and Stem Cell Transplantation; Azienda Sanitaria Universitaria Integrata; Udine Italy
| | - Giulia Benevolo
- Division of Hematology; Città della Salute e della Scienza Hospital; Turin Italy
| | - Alessia Tieghi
- Department of Hematology; A.O. Arcispedale Santa Maria Nuova - IRCCS; Reggio Emilia Italy
| | | | - Massimo Breccia
- Division of Cellular Biotechnologies and Hematology; University Sapienza; Rome Italy
| | | | - Nicola Sgherza
- Division of Hematology; Casa Sollievo Sofferenza; San Giovanni Rotondo Italy
| | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation; ASST Spedali Civili di Brescia; Brescia Italy
| | | | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center; AORMN Hospital; Pesaro Italy
| | - Gianni Binotto
- Hematology and Clinical Immunology Unit; University of Padova; Padova Italy
| | - Florian H. Heidel
- Innere Medizin II, Hämatologie und Onkologie; Universitätsklinikum Jena; Jena Germany
| | | | - Bruno Martino
- Division of Hematology; Azienda Ospedaliera 'Bianchi Melacrino Morelli'; Reggio Calabria Italy
| | - Roberto Latagliata
- Division of Cellular Biotechnologies and Hematology; University Sapienza; Rome Italy
| | - Marco Spinsanti
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology 'L. and A. Seràgnoli'; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
| | - Lydia Kallenberg
- Innere Medizin II, Hämatologie und Onkologie; Universitätsklinikum Jena; Jena Germany
| | | | | | - Luigi Scaffidi
- Department of Hematology; University of Verona; Verona Italy
| | - Antonio Cuneo
- Division of Hematology; University of Ferrara; Ferrara Italy
| | - Michele Cavo
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology 'L. and A. Seràgnoli'; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
| | - Nicola Vianelli
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology 'L. and A. Seràgnoli'; University of Bologna, S. Orsola-Malpighi Hospital; Bologna Italy
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Iurlo A, Cattaneo D. Treatment of Myelofibrosis: Old and New Strategies. Clin Med Insights Blood Disord 2017; 10:1179545X17695233. [PMID: 28579852 PMCID: PMC5428134 DOI: 10.1177/1179545x17695233] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 01/30/2017] [Indexed: 01/19/2023]
Abstract
Myelofibrosis (MF) is a BCR-ABL1-negative myeloproliferative neoplasm that is mainly characterised by reactive bone marrow fibrosis, extramedullary haematopoiesis, anaemia, hepatosplenomegaly, constitutional symptoms, leukaemic progression, and shortened survival. As such, this malignancy is still orphan of curative treatments; indeed, the only treatment that has a clearly demonstrated impact on disease progression is allogeneic haematopoietic stem cell transplantation, but only a minority of patients are eligible for such intensive therapy. However, more recently, the discovery of JAK2 mutations has also led to the development of small-molecule JAK1/2 inhibitors, the first of which, ruxolitinib, has been approved for the treatment of MF in the United States and Europe. In this article, we report on old and new therapeutic strategies that proved effective in early preclinical and clinical trials, and subsequently in the daily clinical practice, for patients with MF, particularly concerning the topics of anaemia, splenomegaly, iron overload, and allogeneic stem cell transplantation.
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Affiliation(s)
- Alessandra Iurlo
- Oncohematology Division, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Daniele Cattaneo
- Oncohematology Division, IRCCS Ca’ Granda – Maggiore Policlinico Hospital Foundation, Milan, Italy
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