1
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Covid-19 in Philadelphia-negative myeloproliferative neoplasms: a GIMEMA survey on incidence, clinical management and vaccine. Leukemia 2022; 36:2548-2550. [PMID: 35963940 PMCID: PMC9375079 DOI: 10.1038/s41375-022-01675-1] [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: 06/02/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/08/2022]
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2
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Saha C, Harrison C. Fedratinib, the first selective JAK2 inhibitor approved for treatment of myelofibrosis - an option beyond ruxolitinib. Expert Rev Hematol 2022; 15:583-595. [PMID: 35787092 DOI: 10.1080/17474086.2022.2098105] [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: 11/04/2022]
Abstract
Introduction: Myelofibrosis, a life shortening clonal disorder, presents with a constellation of features: bone marrow fibrosis, abnormal blood counts, extramedullary hematopoiesis, splenomegaly, thrombohemorrhagic complications and constitutional symptoms. Until recently Ruxolitinib, a JAK1 and 2 inhibitor, has been the only targeted therapy available for transplant-ineligible patients requiring treatment for splenomegaly and disease related symptoms. However, most patients discontinue Ruxolitinib after 3-5 years, mostly due to loss of response. There has been an unmet need for this patient group. In August 2019 Fedratinib (INREBIC® capsules, Impact Biomedicines, Inc., a wholly owned subsidiary of Bristol Meyer Squibb), a JAK2 inhibitor, was approved by US FDA for treatment of myelofibrosis in both JAK inhibitor naïve and pre-treated patients for the management of symptoms and splenomegaly.Areas covered: Here, we discuss the development, evidence base to date for Fedratinib. Including early and late phase, and ongoing trials, safety issues, potential role and current position of Fedratinib in the treatment of myelofibrosis, as well as future direction of targeted therapy in myelofibrosis.Expert opinion: Fedratinib presents a much needed option of treatment, particularly, for patients failing Ruxolitinib, with response rates that are quite similar. Nonetheless, there remain important questions including sequencing and options for combining therapy.
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Affiliation(s)
- Chandan Saha
- Department of Hematology, Guy's and St Thomas' NHS Foundation Trust, London
| | - Claire Harrison
- Department of Hematology, Guy's and St Thomas' NHS Foundation Trust, London
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3
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Levy G, Guglielmelli P, Langmuir P, Constantinescu S. JAK inhibitors and COVID-19. J Immunother Cancer 2022; 10:jitc-2021-002838. [PMID: 35459733 PMCID: PMC9035837 DOI: 10.1136/jitc-2021-002838] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 12/11/2022] Open
Abstract
During SARS-CoV-2 infection, the innate immune response can be inhibited or delayed, and the subsequent persistent viral replication can induce emergency signals that may culminate in a cytokine storm contributing to the severe evolution of COVID-19. Cytokines are key regulators of the immune response and virus clearance, and, as such, are linked to the—possibly altered—response to the SARS-CoV-2. They act via a family of more than 40 transmembrane receptors that are coupled to one or several of the 4 Janus kinases (JAKs) coded by the human genome, namely JAK1, JAK2, JAK3, and TYK2. Once activated, JAKs act on pathways for either survival, proliferation, differentiation, immune regulation or, in the case of type I interferons, antiviral and antiproliferative effects. Studies of graft-versus-host and systemic rheumatic diseases indicated that JAK inhibitors (JAKi) exert immunosuppressive effects that are non-redundant with those of corticotherapy. Therefore, they hold the potential to cut-off pathological reactions in COVID-19. Significant clinical experience already exists with several JAKi in COVID-19, such as baricitinib, ruxolitinib, tofacitinib, and nezulcitinib, which were suggested by a meta-analysis (Patoulias et al.) to exert a benefit in terms of risk reduction concerning major outcomes when added to standard of care in patients with COVID-19. Yet, only baricitinib is recommended in first line for severe COVID-19 treatment by the WHO, as it is the only JAKi that has proven efficient to reduce mortality in individual randomized clinical trials (RCT), especially the Adaptive COVID-19 Treatment Trial (ACTT-2) and COV-BARRIER phase 3 trials. As for secondary effects of JAKi treatment, the main caution with baricitinib consists in the induced immunosuppression as long-term side effects should not be an issue in patients treated for COVID-19. We discuss whether a class effect of JAKi may be emerging in COVID-19 treatment, although at the moment the convincing data are for baricitinib only. Given the key role of JAK1 in both type I IFN action and signaling by cytokines involved in pathogenic effects, establishing the precise timing of treatment will be very important in future trials, along with the control of viral replication by associating antiviral molecules.
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Affiliation(s)
- Gabriel Levy
- Signal Transduction and Molecular Hematology, Ludwig Institute for Cancer Research, Brussels, Belgium.,Signal Transduction on Molecular Hematology, de Duve Institute, Université Catholique de Louvain, Bruxelles, Belgium.,WELBIO, Walloon Excellence in Life Sciences and Biotechnology, Brussels, Belgium
| | - Paola Guglielmelli
- Department of Clinical and Experimental Medicine, University of Florence, Firenze, Italy.,Center of Research and Innovation for Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Peter Langmuir
- Oncology Targeted Therapeutics, Incyte Corp, Wilmington, Delaware, USA
| | - Stefan Constantinescu
- Signal Transduction and Molecular Hematology, Ludwig Institute for Cancer Research, Brussels, Belgium .,Signal Transduction on Molecular Hematology, de Duve Institute, Université Catholique de Louvain, Bruxelles, Belgium.,WELBIO, Walloon Excellence in Life Sciences and Biotechnology, Brussels, Belgium.,Nuffield Department of Medicine, Oxford University, Ludwig Institute for Cancer Research, Oxford, UK
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4
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Cattaneo D, Iurlo A. Immune Dysregulation and Infectious Complications in MPN Patients Treated With JAK Inhibitors. Front Immunol 2021; 12:750346. [PMID: 34867980 PMCID: PMC8639501 DOI: 10.3389/fimmu.2021.750346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/01/2021] [Indexed: 12/12/2022] Open
Abstract
BCR-ABL1-negative myeloproliferative neoplasms are burdened by a reduced life expectancy mostly due to an increased risk of thrombo-hemorrhagic events, fibrotic progression/leukemic evolution, and infectious complications. In these clonal myeloid malignancies, JAK2V617F is the main driver mutation, leading to an aberrant activation of the Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling pathway. Therefore, its inhibition represents an attractive therapeutic strategy for these disorders. Several JAK inhibitors have entered clinical trials, including ruxolitinib, the first JAK1/2 inhibitor to become commercially available for the treatment of myelofibrosis and polycythemia vera. Due to interference with the JAK-STAT pathway, JAK inhibitors affect several components of the innate and adaptive immune systems such as dendritic cells, natural killer cells, T helper cells, and regulatory T cells. Therefore, even though the clinical use of these drugs in MPN patients has led to a dramatic improvement of symptoms control, organ involvement, and quality of life, JAK inhibitors–related loss of function in JAK-STAT signaling pathway can be a cause of different adverse events, including those related to a condition of immune suppression or deficiency. This review article will provide a comprehensive overview of the current knowledge on JAK inhibitors’ effects on immune cells as well as their clinical consequences, particularly with regards to infectious complications.
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Affiliation(s)
- Daniele Cattaneo
- Hematology Division, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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5
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Cattaneo D, Bucelli C, Cavallaro F, Consonni D, Iurlo A. Impact of diagnosis and treatment on response to COVID-19 vaccine in patients with BCR-ABL1-negative myeloproliferative neoplasms. A single-center experience. Blood Cancer J 2021; 11:185. [PMID: 34824194 PMCID: PMC8616716 DOI: 10.1038/s41408-021-00579-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 12/23/2022] Open
Affiliation(s)
- Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Cavallaro
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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6
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Philadelphia-Negative Chronic Myeloproliferative Neoplasms during the COVID-19 Pandemic: Challenges and Future Scenarios. Cancers (Basel) 2021; 13:cancers13194750. [PMID: 34638236 PMCID: PMC8507529 DOI: 10.3390/cancers13194750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/09/2021] [Accepted: 09/17/2021] [Indexed: 12/30/2022] Open
Abstract
An outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) started in December 2019 in China and then become pandemic in February 2020. Several publications investigated the possible increased rate of COVID-19 infection in hematological malignancies. Based on the published data, strategies for the management of chronic Philadelphia-negative chronic myeloproliferative neoplasms (MPNs) are provided. The risk of severe COVID-19 seems high in MPN, particularly in patients with essential thrombocythemia, but not negligible in myelofibrosis. MPN patients are at high risk of both thrombotic and hemorrhagic complications and this must be accounted in the case of COVID-19 deciding on a case-by-case basis. There are currently no data to suggest that hydroxyurea or interferon may influence the risk or severity of COVID-19 infection. Conversely, while the immunosuppressive activity of ruxolitinib might pose increased risk of infection, its abrupt discontinuation during COVID-19 syndrome is associated with worse outcome. All MPN patients should receive vaccine against COVID-19; reassuring data are available on efficacy of mRNA vaccines in MPNs.
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7
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Hasselbalch HC, Skov V, Kjær L, Ellervik C, Poulsen A, Poulsen TD, Nielsen CH. COVID-19 as a mediator of interferon deficiency and hyperinflammation: Rationale for the use of JAK1/2 inhibitors in combination with interferon. Cytokine Growth Factor Rev 2021; 60:28-45. [PMID: 33992887 PMCID: PMC8045432 DOI: 10.1016/j.cytogfr.2021.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 02/08/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) elicits an interferon (IFN) deficiency state, which aggravates the type I interferon deficiency and slow IFN responses, which associate with e.g. aging and obesity. Additionally, SARS-CoV-2 may also elicit a cytokine storm, which accounts for disease progression and ultimately the urgent need of ventilator support. Based upon several reports, it has been argued that early treatment with IFN-alpha2 or IFN-beta, preferentially in the early disease stage, may prohibit disease progression. Similarly, preliminary studies have shown that JAK1/2 inhibitor treatment with ruxolitinib or baricitinib may decrease mortality by dampening the deadly cytokine storm, which - in addition to the virus itself - also contributes to multi-organ thrombosis and multi-organ failure. Herein, we describe the rationale for treatment with IFNs (alpha2 or beta) and ruxolitinib emphasizing the urgent need to explore these agents in the treatment of SARS-CoV-2 - both as monotherapies and in combination. In this context, we take advantage of several safety and efficacy studies in patients with the chronic myeloproliferative blood cancers (essential thrombocythemia, polycythemia vera and myelofibrosis) (MPNs), in whom IFN-alpha2 and ruxolitinib have been used successfully for the last 10 (ruxolitinib) to 30 years (IFN) as monotherapies and most recently in combination as well. In the context of these agents being highly immunomodulating (IFN boosting immune cells and JAK1/2 inhibitors being highly immunosuppressive and anti-inflammatory), we also discuss if statins and hydroxyurea, both agents possessing anti-inflammatory, antithrombotic and antiviral potentials, might be inexpensive agents to be repurposed in the treatment of SARS-CoV-2.
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Affiliation(s)
- H C Hasselbalch
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark.
| | - V Skov
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | - L Kjær
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | - C Ellervik
- Department of Research, Production, Innovation, Region Zealand, Denmark; Department of Pathology, Harvard Medical School, Boston, MA, United States; Department of Laboratory Medicine, Boston Children's Hospital, Boston, MA, United States
| | - A Poulsen
- Department of Anestesiology and Intensive Care Unit, Zealand University Hospital, Roskilde, Denmark
| | - T D Poulsen
- Department of Anestesiology and Intensive Care Unit, Zealand University Hospital, Roskilde, Denmark
| | - C H Nielsen
- Institute for Inflammation Research, Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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8
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Tagliamento M, Agostinetto E, Bruzzone M, Ceppi M, Saini KS, de Azambuja E, Punie K, Westphalen CB, Morgan G, Pronzato P, Del Mastro L, Poggio F, Lambertini M. Mortality in adult patients with solid or hematological malignancies and SARS-CoV-2 infection with a specific focus on lung and breast cancers: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2021; 163:103365. [PMID: 34052423 PMCID: PMC8156831 DOI: 10.1016/j.critrevonc.2021.103365] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A systematic review and meta-analysis was performed to estimate mortality in adult patients with solid or hematological malignancies and SARS-CoV-2 infection. METHODS A systematic search of PubMed, up to 31 January 2021, identified publications reporting the case-fatality rate (CFR) among adult patients with solid or hematological malignancies and SARS-CoV-2 infection. The CFR, defined as the rate of death in this population, was assessed with a random effect model; 95% confidence intervals (CI) were calculated. RESULTS Among 135 selected studies (N = 33,879 patients), the CFR was 25.4% (95% CI 22.9%-28.2%). At a sensitivity analysis including studies with at least 100 patients, the CFR was 21.9% (95% CI 19.1%-25.1%). Among COVID-19 patients with lung (N = 1,135) and breast (N = 1,296) cancers, CFR were 32.4% (95% CI 26.5%-39.6%) and 14.2% (95% CI 9.3%-21.8%), respectively. CONCLUSIONS Patients with solid or hematological malignancies and SARS-CoV-2 infection have a high probability of mortality, with comparatively higher and lower CFRs in patients with lung and breast cancers, respectively.
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Affiliation(s)
- Marco Tagliamento
- Department of Medical Oncology, Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, Genova, Italy
| | - Elisa Agostinetto
- Department of Internal Medicine, Institut Jules Bordet and Université Libre de Bruxelles (ULB), Brussels, Belgium; Humanitas Clinical and Research Center - IRCCS, Humanitas Cancer Center, Rozzano, Milan, Italy
| | - Marco Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marcello Ceppi
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Evandro de Azambuja
- Department of Internal Medicine, Institut Jules Bordet and Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Kevin Punie
- Department of General Medical Oncology and Multidisciplinary Breast Centre, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - C Benedikt Westphalen
- Comprehensive Cancer Center Munich & Department of Medicine III, University Hospital, LMU Munich, Germany
| | - Gilberto Morgan
- Department of Medical and Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | - Paolo Pronzato
- Department of Medical Oncology, Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, Genova, Italy; Breast Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Poggio
- Breast Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genova, Genova, Italy; Department of Medical Oncology, UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy.
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9
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COVID-19 vaccine efficacy in patients with chronic lymphocytic leukemia. Leukemia 2021; 35:2703-2705. [PMID: 33986431 PMCID: PMC8118367 DOI: 10.1038/s41375-021-01270-w] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 12/25/2022]
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10
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Botta C, Indrieri A, Garofalo E, Biamonte F, Bruni A, Pasqua P, Cesario F, Costanzo FS, Longhini F, Mendicino F. COVID-19: High-JAKing of the Inflammatory "Flight" by Ruxolitinib to Avoid the Cytokine Storm. Front Oncol 2021; 10:599502. [PMID: 33489899 PMCID: PMC7819896 DOI: 10.3389/fonc.2020.599502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022] Open
Abstract
Since SARS-CoV-2 outbreak in December 2019, world health-system has been severely impacted with increased hospitalization, Intensive-Care-Unit (ICU) access and high mortality rates, mostly due to severe acute respiratory failure and multi-organ failure. Excessive and uncontrolled release of proinflammatory cytokines (cytokine release/storm syndrome, CRS) have been linked to the development of these events. The recent advancements of immunotherapy for the treatment of hematologic and solid tumors shed light on many of the molecular mechanisms underlying this phenomenon, thus rendering desirable a multidisciplinary approach to improve COVID-19 patients' outcome. Indeed, currently available therapeutic-strategies to overcome CRS, should be urgently evaluated for their capability of reducing COVID-19 mortality. Notably, COVID-19 shares different pathogenic aspects with acute graft-versus-host-disease (aGVHD), hemophagocytic-lymphohistiocytosis (HLH), myelofibrosis, and CAR-T-associated CRS. Specifically, similarly to aGVHD, an induced tissue damage (caused by the virus) leads to increased cytokine release (TNFα and IL-6) which in turn leads to exaggerated dendritic cells, macrophages (like in HLH) and lymphocytes (as in CAR-T) activation, immune-cells migration, and tissue-damage (including late-stage fibrosis, similar to myelofibrosis). Janus Kinase (JAK) signaling represents a molecular hub linking all these events, rendering JAK-inhibitors suitable to limit deleterious effects of an overwhelming inflammatory-response. Accordingly, ruxolitinib is the only selective JAK1 and JAK2-inhibitor approved for the treatment of myelofibrosis and aGVHD. Here, we discuss, from a molecular and hematological point of view, the rationale for targeting JAK signaling in the management of COVID-19 patients and report the clinical results of a patient admitted to ICU among the firsts to be treated with ruxolitinib in Italy.
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Affiliation(s)
- Cirino Botta
- Hematology Unit, Department of Hemato-Oncology, "Annunziata" Hospital of Cosenza, Cosenza, Italy
| | - Alessia Indrieri
- Telethon Institute of Genetics and Medicine (TIGEM), Pozzuoli, Italy
- Institute for Genetic and Biomedical Research (IRGB), National Research Council (CNR), Milan, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Flavia Biamonte
- Department of Clinical and Experimental Medicine, "Magna Graecia" University, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Pino Pasqua
- Anesthesia and Intensive Care Unit, "Annunziata" Hospital of Cosenza, Cosenza, Italy
| | - Francesco Cesario
- Hematology Unit, Department of Hemato-Oncology, "Annunziata" Hospital of Cosenza, Cosenza, Italy
| | | | - Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Francesco Mendicino
- Hematology Unit, Department of Hemato-Oncology, "Annunziata" Hospital of Cosenza, Cosenza, Italy
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11
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Barbui T, Vannucchi AM, Alvarez-Larran A, Iurlo A, Masciulli A, Carobbio A, Ghirardi A, Ferrari A, Rossi G, Elli E, Andrade-Campos MM, Kabat MG, Kiladjian JJ, Palandri F, Benevolo G, Garcia-Gutierrez V, Fox ML, Foncillas MA, Morcillo CM, Rumi E, Osorio S, Papadopoulos P, Bonifacio M, Cervantes KSQ, Serrano MS, Carreno-Tarragona G, Sobas MA, Lunghi F, Patriarca A, Elorza BN, Angona A, Mazo EM, Koschmieder S, Ruggeri M, Cuevas B, Hernandez-Boluda JC, Abadia EL, Cirici BX, Guglielmelli P, Garrote M, Cattaneo D, Daffini R, Cavalca F, Bellosillo B, Benajiba L, Curto-Garcia N, Bellini M, Betti S, De Stefano V, Harrison C, Rambaldi A. High mortality rate in COVID-19 patients with myeloproliferative neoplasms after abrupt withdrawal of ruxolitinib. Leukemia 2021; 35:485-493. [PMID: 33414483 PMCID: PMC7789078 DOI: 10.1038/s41375-020-01107-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/29/2020] [Accepted: 11/27/2020] [Indexed: 11/13/2022]
Abstract
We report the clinical presentation and risk factors for survival in 175 patients with myeloproliferative neoplasms (MPN) and COVID-19, diagnosed between February and June 2020. After a median follow-up of 50 days, mortality was higher than in the general population and reached 48% in myelofibrosis (MF). Univariate analysis, showed a significant relationship between death and age, male gender, decreased lymphocyte counts, need for respiratory support, comorbidities and diagnosis of MF, while no association with essential thrombocythemia (ET), polycythemia vera (PV), and prefibrotic-PMF (pre-PMF) was found. Regarding MPN-directed therapy ongoing at the time of COVID-19 diagnosis, Ruxolitinib (Ruxo) was significantly more frequent in patients who died in comparison with survivors (p = 0.006). Conversely, multivariable analysis found no effect of Ruxo alone on mortality, but highlighted an increased risk of death in the 11 out of 45 patients who discontinued treatment. These findings were also confirmed in a propensity score matching analysis. In conclusion, we found a high risk of mortality during COVID-19 infection among MPN patients, especially in MF patients and/or discontinuing Ruxo at COVID-19 diagnosis. These findings call for deeper investigation on the role of Ruxo treatment and its interruption, in affecting mortality in MPN patients with COVID-19.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Alessandro Maria Vannucchi
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | | | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Arianna Masciulli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Arianna Ghirardi
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alberto Ferrari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Elena Elli
- Ospedale San Gerardo, ASST Monza, Monza, Italy
| | | | | | | | - Francesca Palandri
- Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italia
| | - Giulia Benevolo
- AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Maria Laura Fox
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, C/ Natzaret, 115-117, 08035, Barcelona, Spain
| | | | | | - Elisa Rumi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | | | | | | | | | | | - Marta Anna Sobas
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | | | | | | | - Anna Angona
- ICO Girona Hospital Josep Trueta, Girona, Spain
| | - Elena Magro Mazo
- Hospital Universitario Principe de Asturias, Alcalà de Henares, Madrid, Spain
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | | | | | | | | | | | - Paola Guglielmelli
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | | | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | | | | | | | | | - Silvia Betti
- Fondazione Policlinico "A. Gemelli" IRCCS, Rome, Italy
| | | | | | - Alessandro Rambaldi
- ASST Papa Giovanni XXIII, Bergamo, Italy.,Università degli Studi di Milano, Milano, Italy
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12
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Abstract
PURPOSE OF REVIEW The spread of the novel coronavirus SARS-CoV-2 and its associated disease, coronavirus disease of 2019 (COVID-19), has significantly derailed cancer care. Patients with leukemia are more likely to have severe infection and increased rates of mortality. There is paucity of information on how to modify care of leukemia patients in view of the COVID-19 risks and imposed restrictions. We review the available literature on the impact of COVID-19 on different types of leukemia patients and suggest general as well as disease-specific recommendations on care based on available evidence. RECENT FINDINGS The COVID-19 infection impacts leukemia subtypes in variable ways and the standard treatments for leukemia have similarly, varying effects on the course of COVID-19 infection. Useful treatment strategies include deferring treatment when possible, use of less intensive regimens, outpatient targeted oral agents requiring minimal monitoring, and prioritization of curative or life-prolonging strategies. Reducing health care encounters, rational transfusion standards, just resource allocation, and pre-emptive advance care planning will serve the interests of leukemia patients. Ad hoc modifications based on expert opinions and extrapolations of previous well-designed studies are the way forward to navigate the crisis. This should be supplanted with more rigorous prospective evidence.
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Sadjadian P, Wille K, Griesshammer M. Ruxolitinib-Associated Infections in Polycythemia Vera: Review of the Literature, Clinical Significance, and Recommendations. Cancers (Basel) 2020; 12:cancers12113132. [PMID: 33114733 PMCID: PMC7693745 DOI: 10.3390/cancers12113132] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Polycythemia vera (PV) is a chronic blood disease characterized by elevated red blood cells and splenomegaly. About 98% of all PV patients harbor the JAK2 mutation. Ruxolitinib (RUX), a JAK1/JAK2 inhibitor, received approval as a second-line indication in PV patients who are resistant or intolerant to standard therapy hydroxyurea in both the United States (2014) and Europe (2015). In the studies relevant to approval, RUX achieved excellent PV control. Due to its mechanism of action, RUX also has immunosuppressive effects. As expected, an increased rate of infection was observed in clinical studies and in practical application. In this overview, we have compiled all previous literature references on RUX and infections in PV. However, apart from a few individual cases with special infections and an increased rate of zoster infections, there are no exceptional high infection problems. Recommendations are given on how infections in RUX treated PV patients can be avoided. Abstract Ruxolitinib (RUX), a JAK1/JAK2 inhibitor, is approved for second-line therapy in patients with polycythemia vera (PV) who are resistant or intolerant to hydroxyurea. Due to the immunomodulatory and immunosuppressive effect of RUX, there is an increased susceptibility to infections. However, an increased risk of infection is inherent to even untreated myeloproliferative neoplasms (MPN). To obtain more information on the clinical significance of RUX-associated infections in PV, we reviewed the available literature. There is no evidence-based approach to managing infection risks. Most data on RUX-associated infections are available for MF. In all studies, the infection rates in the RUX and control groups were fairly similar, with the exception of infections with the varicella zoster virus (VZV). However, individual cases of bilateral toxoplasmosis retinitis, disseminated molluscum contagiosum, or a mycobacterium tuberculosis infection or a hepatitis B reactivation are reported. A careful assessment of the risk of infection for PV patients is required at the initial presentation and before the start of RUX. Screening for hepatitis B is recommended in all patients. The risk of RUX-associated infections is lower with PV than with MF, but compared to a normal population there is an increased risk of VZV infection. However, primary VZV prophylaxis for PV patients is not recommended, while secondary prophylaxis can be considered individually. As early treatment is most effective for VZV, patients should be properly informed and trained to seek medical advice immediately if cutaneous signs of VZV develop. Vaccination against influenza, herpes zoster, and pneumococci should be considered in all PV patients at risk of infection, especially if RUX treatment is planned. Current recommendations do not support adjusting or discontinuing JAK inhibition in MPN patients to reduce the risk of COVID-19.
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