Association of pleural effusion with an early molecular response in patients with newly diagnosed chronic-phase chronic myeloid leukemia receiving dasatinib: Results of a D-First study

Unilateral Interstitial Lung Disease with Contralateral Effusion: Unusual Case Report of Dasatinib Toxicity

Dasatinib is a second-generation tyrosine kinase inhibitor (TKI) used in chronic myelogenous leukemia (CML). While pleural effusion due to Dasatinib is well described in the literature, interstitial lung disease (ILD) caused by it is rare. A 60-year-old gentleman was on treatment with 100 mg of tablet Dasatinib per day for chronic myeloid leukemia. He presented to the outpatient department with history of progressive breathlessness over 2 months. High-resolution computerized tomography (HRCT) thorax revealed mild right-sided effusion and non-specific interstitial pneumonia (NSIP) pattern of ILD in the left lower lobe. Thoracocentesis of the right-sided pleural effusion showed exudative and lymphocytic rich pleural effusion. The effusion was negative for malignant cells or infection. Biopsy of the left lower lobe was consistent with the diagnosis of ILD. He was started on prednisolone which was gradually tapered and stopped. At 3 months, there was a complete resolution of the ILD and pleural effusion. Clinicians need to be aware about the pleuroparenchymal toxicities of Dasatinib. Early diagnosis and treatment with steroids can lead to complete resolution of the signs and symptoms.

Dasatinib dose optimisation based on therapeutic drug monitoring reduces pleural effusion rates in chronic myeloid leukaemia patients

Dasatinib is a second-generation BCR-ABL1 tyrosine kinase inhibitor approved for patients with chronic myeloid leukaemia (CML). Dasatinib 100 mg per day is associated with an increased risk of pleural effusion (PlEff). We randomly evaluated whether therapeutic drug monitoring (TDM) may reduce dasatinib-associated significant adverse events (AEs) by 12 months (primary endpoint). Eligible patients started dasatinib at 100 mg per day followed by dasatinib (C)min assessment. Patients considered overdosed [(C)min ≥ 3 nmol/l) were randomised between a dose-reduction strategy (TDM arm) and standard of care (control arm). Out of 287 evaluable patients, 80 patients were randomised. The primary endpoint was not met due to early haematological AEs occurring before effective dose reduction. However, a major reduction in the cumulative incidence of PlEff was observed in the TDM arm compared to the control arm (4% vs. 15%; 11% vs. 35% and 12% vs. 39% at one, two and three years, respectively (P = 0·0094)). Molecular responses were superimposable in all arms. Dasatinib TDM during treatment initiation was feasible and resulted in a significant reduction of the incidence of PlEff in the long run, without impairing molecular responses. (NCT01916785; https://clinicaltrials.gov).

[Dasatinib-related pulmonary adverse events in patients with chronic myeloid leukemia]

目的

探索慢性髓性白血病（CML）患者接受达沙替尼治疗中肺部不良反应的发生率、影响因素及治疗转归。

方法

回顾性分析2008年4月至2020年1月在北京大学人民医院接受达沙替尼治疗的CML患者胸腔积液（PE）和肺动脉高压（PAH）的发生情况。

结果

共纳入280例患者，中位达沙替尼治疗时间26（1～142）个月，发现PE 90例（32.1％），其中1级40例（44.4％），2级44例（48.9％），3级6例（6.7％）。PE发生率随服药时间延长逐渐升高，多因素分析结果显示，年龄增加（每增加10岁，HR＝1.6，P<0.001）、服用达沙替尼时处于进展期（HR＝2.2，P＝0.008）和有心血管疾病合并症（HR＝1.9，P＝0.018）与PE发生显著相关。服用达沙替尼时处于进展期（HR＝3.4，P＝0.001）、确诊至开始服用酪氨酸激酶抑制剂时间≤6个月（HR＝2.2，P＝0.015）、发现PE时剂量<100 mg/d（HR＝3.1，P＝0.001）者PE程度更重。经减停达沙替尼、利尿、胸腔穿刺或置管等干预，半数患者PE减少或消失。减量服用达沙替尼的患者中，绝大多数可维持原治疗反应。在有咳嗽、胸闷或气促等症状的60例患者中，49例接受超声心动图（UCG）检查，8例（16.3％）发现PAH高度可能性，约占所有患者中的3.5％，其中6例（75.0％）合并PE，PAH为可逆性。原研与国产达沙替尼的PE和PAH发生率差异无统计学意义（P>0.05）。

结论

在服用达沙替尼的CML患者中，PE是常见的不良反应，PAH较少见，应注意识别高危人群、密切监测和及时干预。

Comparative Safety and Health Care Expenditures Among Patients With Chronic Myeloid Leukemia Initiating First-Line Imatinib, Dasatinib, or Nilotinib

PURPOSE

Tyrosine kinase inhibitors (TKIs) have dramatically improved survival for patients with chronic myeloid leukemia (CML). No overall survival differences were observed between patients initiating first- and second-generation TKIs in trials; however, real-world safety and cost outcomes are unclear. We evaluated comparative safety and health care expenditures between first-line imatinib, dasatinib, and nilotinib among patients with CML.

PATIENTS AND METHODS

Eligible patients had one or more fills for imatinib, dasatinib, or nilotinib in the MarketScan Commercial and Medicare Supplemental databases between January 1, 2011, and December 31, 2016 (earliest fill is the index date), 6 months pre-index continuous enrollment, CML diagnosis, and no TKI use in the pre-index period. Hospitalizations or emergency department visits (safety events) were compared across treatment groups using propensity-score-weighted 1-year relative risks (RRs) and subdistribution hazard ratios (HRs). Inflation-adjusted annual health care expenditures were compared using quantile regression.

RESULTS

Eligible patients included 1,417 receiving imatinib, 1,067 receiving dasatinib, and 647 receiving nilotinib. The 1-year risk of safety events was high: imatinib, 37%; dasatinib, 44%; and nilotinib, 40%, with higher risks among patients receiving dasatinib (RR, 1.17; 95% CI, 1.06 to 1.30) and nilotinib (RR, 1.07; 95% CI, 0.93 to 1.23) compared with those receiving imatinib. Over a median of 1.7 years, the cumulative incidence of safety events was higher among patients receiving dasatinib (HR, 1.23; 95% CI, 1.10 to 1.38) and nilotinib (HR, 1.08; 95% CI, 0.95 to 1.24) than among those receiving imatinib. One-year health care expenditures were high (median, $125,987) and were significantly higher among patients initiating second-generation TKIs compared with those receiving imatinib (difference in medians: dasatinib v imatinib, $22,393; 95% CI, $17,068 to $27,718; nilotinib v imatinib, $19,463; 95% CI, $14,689 to $24,236).

CONCLUSION

Patients receiving imatinib had the lowest risk of hospitalization or emergency department visits and 1-year health care expenditures. Given a lack of significant differences in overall survival, imatinib may represent the ideal first-line therapy for patients, on average.

Influence of proton pump inhibitors and H2-receptor antagonists on the efficacy and safety of dasatinib in chronic myeloid leukemia patients

We evaluated the effect of proton pump inhibitors (PPIs) and H2-receptor antagonists (H2RAs) on the efficacy and safety of dasatinib for chronic-phase chronic myeloid leukemia (CP-CML). Retrospective analyses were performed for patients with CP-CML who received dasatinib at seven hospitals between April 2009 and December 2016. Seventy-three patients were identified, 16 of whom received PPIs or H2RAs concurrently with dasatinib. Major molecular response at 12 months was observed in 13 of 13 patients (100%) with concurrent PPIs or H2RAs (combination group), and in 23 of 51 patients (45.1%) who received only dasatinib (dasatinib-alone group; P < 0.001). Deep molecular response at 12 months was observed in four of six patients (66.7%) in the combination group, and seven of 38 patients (18.4%) in the dasatinib-alone group (P = 0.027). Dasatinib chemotherapy was stopped after 18 months for 25 patients (43.9%) from the dasatinib-alone group, but for none from the combination group. Combination treatment with PPIs or H2RAs did not reduce the efficacy of dasatinib. PPIs and H2RAs reduce the incidence of dasatinib discontinuation due to adverse events and increase the efficacy of dasatinib chemotherapy for patients.

Discontinuation of tyrosine kinase inhibitors in CML patients in real-world clinical practice at a single institution

BACKGROUND

Most patients with chronic myeloid leukemia (CML) treated with tyrosine kinase inhibitors (TKIs) will relapse if treatment is withdrawn, but various trials have recently demonstrated that a significant proportion of patients who achieved a stable and deep molecular response (DMR) can stop therapy without relapsing. However, most information on treatment cessation was obtained from clinical trials with strict recruiting criteria.

METHODS

We evaluated the outcome of 25 patients with CML that discontinued TKI therapy in our institute in real-world clinical practice.

RESULTS

Of the 25 patients, 76% discontinued therapy in sustained deep molecular response (SDMR) and 24% were in unsustained DMR (UDMR). Discontinuation of therapy due to adverse effects was observed in 5 and 50% of the patients in the SDMR and UDMR groups, respectively. After TKI discontinuation, patients were followed for a median of 24 months. At the time of this analysis, 56% patients had a molecular relapse after a median of 4 months. SDMR and longer treatment duration were associated with lower probability of molecular relapse: 25% in SDMR patients with TKI treatment > 96 months and 85% in UDMR patients with TKI treatment ≤96 months. All relapsed patients promptly resumed TKI therapy and regained at least major molecular response (MMR).

CONCLUSIONS

Our results suggest that TKI discontinuation is safe outside clinical trials and particularly effective in CML patients who are in SDMR with longer TKI treatment duration.

Thrombopoietin Levels During Tyrosine Kinase Inhibitor Therapy for Chronic Myeloid Leukemia

BACKGROUND AND OBJECTIVE

Although it is well known that platelet depletion is one of the major adverse events related to tyrosine kinase inhibitor (TKI) therapy, the effect of TKIs on thrombopoietin (TPO), a stimulating factor for thrombopoiesis, has not been examined to date. In this study, we investigated the effect of TKIs on the levels of plasma TPO concentration in patients with well-controlled chronic myeloid leukemia receiving imatinib or dasatinib and those in treatment-free remission (TFR).

METHODS

Blood samples for blood cell counts and plasma TPO levels were obtained from 23 dasatinib-treated patients before and 1 h after intake, 11 patients treated with imatinib before and 2 h after intake, and nine TFR patients. Levels of plasma TPO were determined by using enzyme-linked immunosorbent assays.

RESULTS

Levels of TPO were significantly inversely correlated with platelet counts in the entire cohort (r = - 0.568, p < 0.0001). Dasatinib intake, but not imatinib, significantly reduced platelet counts after intake (p = 0.0009 in dasatinib and p = 0.5431 in imatinib). However, imatinib and dasatinib intake increased the levels of TPO in these patients (p = 0.0024, dasatinib; p = 0.0098, imatinib).

CONCLUSIONS

Our study results suggest that neither dasatinib nor imatinib therapy inhibits TPO production. Rather, transient increases in TPO levels seen with these two treatments might be a result of the decrease in TPO clearance these TKIs confer. However, further investigations are required to clarify the effect of TKIs on thrombopoiesis.

Clinical significance of dasatinib-induced pleural effusion in patients with de novo chronic myeloid leukemia

Dasatinib is currently approved for clinical use as a first-line treatment agent for newly diagnosed chronic myeloid leukemia (CML). However, only a few clinical trials have been performed to evaluate dasatinibinduced PE following first-line therapy. We investigated the incidence and clinical features of dasatinib-induced PE following first-line therapy in Japanese CML patients of real world clinical practice settings. Among 22 patients, the median age of PE-positive patients was higher than that of PE-negative patients. Major molecular response was achieved in 75% of PE-positive patients and 50% of PE-negative patients. Most patients developed PE more than 1 year after treatment. Appearance of PE is associated with better clinical response during dasatinib treatment, however it is developed at any time. Elderly and high-risk patients tend to develop PE. The clinical features of dasatinib-induced PE following first-line therapy might be late onset and might not immediately follow the increasing of large granular lymphocyte.

A 68-Year-Old Man With Chronic Myelogenous Leukemia and a Large Unilateral Pleural Effusion

CASE PRESENTATION

A 68-year-old man with chronic myelogenous leukemia presents for evaluation of 2 months of dyspnea with exertion. He denies cough, fever, chest pain, weight gain, orthopnea, and edema. Since diagnosis of chronic myelogenous leukemia 5 years ago, he has been treated with dasatinib, with recent BCR-ABL1 assay showing no detectable disease in the peripheral blood. Medical history also includes hyperlipidemia, prostate enlargement, and hypothyroidism, but no prior heart or lung disease. Born in the Middle East, he immigrated to the United States 30 years ago and is working as a physician. He received the Bacillus Calmette-Guérin vaccine as a child. Quantiferon Gold test 1 year ago was positive (TB antigen response 0.91, reference range in <0.35), but he has not received treatment for this. He is a lifelong nonsmoker and rarely drinks alcohol. Medications include dasatinib, rosuvastatin, levothyroxine, tamsulosin, and dutasteride.

The Efficacy of Reduced-dose Dasatinib as a Subsequent Therapy in Patients with Chronic Myeloid Leukemia in the Chronic Phase: The LD-CML Study of the Kanto CML Study Group

Objective The aim of this study was to prospectively investigate the efficacy and safety profiles of low-dose dasatinib therapy (50 mg once daily). Methods Patients with chronic myeloid leukemia in the chronic phase (CML-CP) who were being treated with low-dose imatinib (≤200 mg/day), but were resistant to this agent were enrolled in the current study (referred to as the LD-CML study). Results There subjects included 9 patients (4 men and 5 women); all were treated with dasatinib at a dose of 50 mg once daily. Among 8 patients who had not experienced major molecular response (MMR; BCR-ABL1 transcript ≤0.1% according to International Scale [IS]) at study enrollment, 5 attained MMR by 12 months. In particular, 3 of 9 patients demonstrated a deep molecular response (DMR; IS ≤0.0069%) by 18 months. Five patients developed lymphocytosis accompanied by cytotoxic lymphocyte predominance. There was no mortality or disease progression, and all continue to receive dasatinib therapy at 18 months with only 2 patients requiring dose reduction. Toxicities were mild-to-moderate, and pleural effusion was observed in 1 patient (grade 1). Conclusion Low-dose dasatinib can attain MMR and DMR without severe toxicity in patients with CML-CP who are unable to achieve MMR with low-dose imatinib. Switching to low-dose dasatinib should therefore be considered for patients in this setting, especially if they are otherwise considering a cessation of treatment.