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Krecak I, Verstovsek S, Lucijanic M. Optimization of cardiovascular risk factor management in patients with BCR::ABL1 negative chronic myeloproliferative neoplasms, current knowledge, and perspectives. Ann Hematol 2024; 103:1513-1523. [PMID: 37665349 DOI: 10.1007/s00277-023-05426-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
The exact prognostic role of cardiovascular (CV) risk factors in patients with BCR::ABL1 negative chronic myeloproliferative neoplasms (MPNs) remains unknown as it is often masked by other MPN-related features that bear strong prognostic impact on thrombotic risk. Therefore, current MPN treatment is not primarily guided by presence of CV risk factors. Treatment of CV risk factors in MPN patients usually mirrors that from the general population, despite the fact that CV risk factors in MPNs have their own specificities. Moreover, the optimal target levels for different metabolic deflections in MPNs (i.e., low-density lipoprotein, serum uric acid, or glycated hemoglobin levels) have not been defined. In the current review, we separately discuss the most important aspects of every individual CV risk factor (arterial hypertension, hyperlipidemia, chronic kidney disease, smoking, diabetes mellitus, hyperuricemia, and obesity and cachexia) in MPNs, summarize recent advances in the field, and propose future directions and research areas which may be needed to appropriately manage CV risk factors in MPNs.
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Affiliation(s)
- Ivan Krecak
- Department of Internal Medicine, General Hospital of Sibenik-Knin County, Stjepana Radića 83, 22000, Sibenik, Croatia.
- Faculty of Medicine, University of Rijeka, Rijeka, Croatia.
- University of Applied Sciences, Sibenik, Croatia.
| | | | - Marko Lucijanic
- Department of Hematology, University Hospital Dubrava, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Pasquer H, Daltro de Oliveira R, Vasseur L, Soret-Dulphy J, Maslah N, Zhao LP, Marcault C, Cazaux M, Gauthier N, Verger E, Parquet N, Vainchenker W, Raffoux E, Ugo V, Luque Paz D, Roy L, Lambert WC, Ianotto JC, Lippert E, Giraudier S, Cassinat B, Kiladjian JJ, Benajiba L. Distinct clinico-molecular arterial and venous thrombosis scores for myeloproliferative neoplasms risk stratification. Leukemia 2024; 38:326-339. [PMID: 38148396 DOI: 10.1038/s41375-023-02114-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/28/2023]
Abstract
Current recommended risk scores to predict thrombotic events associated with myeloproliferative neoplasms (MPN) do not discriminate between arterial and venous thrombosis despite their different physiopathology. To define novel stratification systems, we delineated a comprehensive landscape of MPN associated thrombosis across a large long-term follow-up MPN cohort. Prior arterial thrombosis, age >60 years, cardiovascular risk factors and presence of TET2 or DNMT3A mutations were independently associated with arterial thrombosis in multivariable analysis. ARTS, an ARterial Thrombosis Score, based on these four factors, defined low- (0.37% patients-year) and high-risk (1.19% patients-year) patients. ARTS performance was superior to the two-tiered conventional risk stratification in our training cohort, across all MPN subtypes, as well as in two external validation cohorts. Prior venous thrombosis and presence of a JAK2V617F mutation with a variant allelic frequency ≥50% were independently associated with venous thrombosis. The discrimination potential of VETS, a VEnous Thrombosis Score based on these two factors, was poor, similar to the two-tiered conventional risk stratification. Our study pinpoints arterial and venous thrombosis clinico-molecular differences and proposes an arterial risk score for more accurate patients' stratification. Further improvement of venous risk scores, accounting for additional factors and considering venous thrombosis as a heterogeneous entity is warranted.
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Affiliation(s)
- Hélène Pasquer
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
- INSERM UMR 944, Institut de Recherche Saint-Louis, Paris, France
| | - Rafael Daltro de Oliveira
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
| | - Loic Vasseur
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
| | - Juliette Soret-Dulphy
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
| | - Nabih Maslah
- Université Paris Cité, APHP, Hôpital Saint-Louis, Laboratoire de Biologie Cellulaire, Paris, France
- INSERM UMR 1131, Institut de Recherche Saint-Louis, Paris, France
| | - Lin-Pierre Zhao
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
| | - Clémence Marcault
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
| | - Marine Cazaux
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
| | - Nicolas Gauthier
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
| | - Emmanuelle Verger
- Université Paris Cité, APHP, Hôpital Saint-Louis, Laboratoire de Biologie Cellulaire, Paris, France
- INSERM UMR 1131, Institut de Recherche Saint-Louis, Paris, France
| | - Nathalie Parquet
- Université Paris Cité, APHP, Hôpital Saint-Louis, Département d'hématologie et d'Immunologie, Paris, France
| | - William Vainchenker
- APHP, Hôpital Saint-Louis, Département d'hématologie et d'Immunologie, Paris, France
| | - Emmanuel Raffoux
- Université Paris Cité, APHP, Hôpital Saint-Louis, Département d'hématologie et d'Immunologie, Paris, France
| | - Valérie Ugo
- Univ Angers, Nantes Université, CHU Angers, Inserm, CNRS, CRCI2NA, Angers, France
| | - Damien Luque Paz
- Univ Angers, Nantes Université, CHU Angers, Inserm, CNRS, CRCI2NA, Angers, France
| | - Lydia Roy
- Université Paris Est Créteil, APHP, Hôpital Henri Mondor, Service d'hématologie, Créteil, France
| | - Wayne-Corentin Lambert
- Université de Bretagne Occidentale, CHU de Brest, Service d'Hématologie Biologique, Brest, France
| | - Jean-Christophe Ianotto
- Université de Bretagne Occidentale, CHU de Brest, Service d'Hématologie et d'Hémostase Clinique, Brest, France
| | - Eric Lippert
- Université de Bretagne Occidentale, CHU de Brest, Service d'Hématologie Biologique, Brest, France
| | - Stéphane Giraudier
- Université Paris Cité, APHP, Hôpital Saint-Louis, Laboratoire de Biologie Cellulaire, Paris, France
- INSERM UMR 1131, Institut de Recherche Saint-Louis, Paris, France
| | - Bruno Cassinat
- Université Paris Cité, APHP, Hôpital Saint-Louis, Laboratoire de Biologie Cellulaire, Paris, France
- INSERM UMR 1131, Institut de Recherche Saint-Louis, Paris, France
| | - Jean-Jacques Kiladjian
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France
- INSERM UMR 1131, Institut de Recherche Saint-Louis, Paris, France
| | - Lina Benajiba
- Université Paris Cité, APHP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM CIC 1427, Paris, France.
- INSERM UMR 944, Institut de Recherche Saint-Louis, Paris, France.
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3
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Duminuco A, Harrington P, Harrison C, Curto-Garcia N. Polycythemia Vera: Barriers to and Strategies for Optimal Management. Blood Lymphat Cancer 2023; 13:77-90. [PMID: 38146420 PMCID: PMC10749566 DOI: 10.2147/blctt.s409443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/16/2023] [Indexed: 12/27/2023]
Abstract
Polycythemia vera (PV) is a subtype of myeloproliferative neoplasms characterized by impaired quality of life and severe complications. Despite the increasingly in-depth knowledge of this condition, it necessitates a multifaceted management approach to mitigate symptoms and prevent thrombotic and hemorrhagic events, ensuring prolonged survival. The therapeutic landscape has been revolutionized in recent years, where venesection and hydroxycarbamide associated with antiplatelet therapy have a central role and are now accompanied by other drugs, such as interferon and Janus kinase inhibitors. Ongoing research and advancements in targeted therapies hold promise for further enhancing the therapeutic choice for PV management.
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Affiliation(s)
- Andrea Duminuco
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Haematology with BMT Unit, A.O.U. Policlinico “G.Rodolico-San Marco”, Catania, Italy
| | - Patrick Harrington
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Claire Harrison
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Natalia Curto-Garcia
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Gill H, Leung GMK, Ooi MGM, Teo WZY, Wong CL, Choi CW, Wong GC, Lao Z, Rojnuckarin P, Castillo MRID, Xiao Z, Hou HA, Kuo MC, Shih LY, Gan GG, Lin CC, Chng WJ, Kwong YL. Management of classical Philadelphia chromosome-negative myeloproliferative neoplasms in Asia: consensus of the Asian Myeloid Working Group. Clin Exp Med 2023; 23:4199-4217. [PMID: 37747591 DOI: 10.1007/s10238-023-01189-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Myeloproliferative neoplasms (MPN) are a heterogeneous group of clonal hematopoietic stem cell disorders characterized clinically by the proliferation of one or more hematopoietic lineage(s). The classical Philadelphia-chromosome (Ph)-negative MPNs include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). The Asian Myeloid Working Group (AMWG) comprises representatives from fifteen Asian centers experienced in the management of MPN. This consensus from the AMWG aims to review the current evidence in the risk stratification and treatment of Ph-negative MPN, to identify management gaps for future improvement, and to offer pragmatic approaches for treatment commensurate with different levels of resources, drug availabilities and reimbursement policies in its constituent regions. The management of MPN should be patient-specific and based on accurate diagnostic and prognostic tools. In patients with PV, ET and early/prefibrotic PMF, symptoms and risk stratification will guide the need for early cytoreduction. In younger patients requiring cytoreduction and in those experiencing resistance or intolerance to hydroxyurea, recombinant interferon-α preparations (pegylated interferon-α 2A or ropeginterferon-α 2b) should be considered. In myelofibrosis, continuous risk assessment and symptom burden assessment are essential in guiding treatment selection. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) in MF should always be based on accurate risk stratification for disease-risk and post-HSCT outcome. Management of classical Ph-negative MPN entails accurate diagnosis, cytogenetic and molecular evaluation, risk stratification, and treatment strategies that are outcome-oriented (curative, disease modification, improvement of quality-of-life).
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Affiliation(s)
- Harinder Gill
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China.
- Department of Medicine, Professorial Block, Queen Mary Hospital, Pokfulam Road, Pok Fu Lam, Hong Kong, China.
| | - Garret M K Leung
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
| | - Melissa G M Ooi
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Winnie Z Y Teo
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Fast and Chronic Program, Alexandra Hospital, Singapore, Singapore
| | - Chieh-Lee Wong
- Department of Medicine, Sunway Medical Centre, Shah Alam, Selangor, Malaysia
| | - Chul Won Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gee-Chuan Wong
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Zhentang Lao
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Ponlapat Rojnuckarin
- King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | | | - Zhijian Xiao
- Blood Disease Hospital and Institute of Hematology, Chinese Academy of Medical Sciences Peking Union Medical College, Tianjin, China
| | - Hsin-An Hou
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chung Kuo
- Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Lee-Yung Shih
- Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Gin-Gin Gan
- University of Malaya, Kuala Lumpur, Malaysia
| | - Chien-Chin Lin
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wee-Joo Chng
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Yok-Lam Kwong
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
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Benevolo G, Marchetti M, Melchio R, Beggiato E, Sartori C, Biolé CA, Rapezzi D, Bruno B, Milan A. Diagnosis and Management of Cardiovascular Risk in Patients with Polycythemia Vera. Vasc Health Risk Manag 2023; 19:765-778. [PMID: 38025519 PMCID: PMC10676644 DOI: 10.2147/vhrm.s429995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023] Open
Abstract
Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by aberrant myeloid lineage hematopoiesis with excessive red blood cell and pro-inflammatory cytokine production. Patients with PV present with a range of thrombotic and hemorrhagic symptoms that affect quality of life and reduce overall survival expectancy. Thrombotic events, transformation into acute myeloid leukemia, and myelofibrosis are largely responsible for the observed mortality. Treatment of PV is thus primarily focused on symptom control and survival extension through the prevention of thrombosis and leukemic transformation. Patients with PV frequently experience thrombotic events and have elevated cardiovascular risk, including hypertension, dyslipidemias, obesity, and smoking, all of which negatively affect survival. To reduce the risk of thrombotic complications, PV therapy should aim to normalize hemoglobin, hematocrit, and leukocytosis and, in addition, identify and modify cardiovascular risk factors. Herein, we review what is currently known about the associated cardiovascular risk and propose strategies for diagnosing and managing patients with PV.
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Affiliation(s)
- Giulia Benevolo
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Monia Marchetti
- Hematology and Transplant Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Remo Melchio
- Division of Internal Medicine, A.O. S. Croce E Carle, Cuneo, Italy
| | - Eloise Beggiato
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Sartori
- Cardiology, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | | | - Benedetto Bruno
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Molecular Biotechnolgies and Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Milan
- Department of Medical Sciences, University of Turin, Città della Salute e della Scienza di Torino, Turin, Italy
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Verstovsek S, Krečak I, Heidel FH, De Stefano V, Bryan K, Zuurman MW, Zaiac M, Morelli M, Smyth A, Redondo S, Bigan E, Ruhl M, Meier C, Beffy M, Kiladjian JJ. Identifying Patients with Polycythemia Vera at Risk of Thrombosis after Hydroxyurea Initiation: The Polycythemia Vera-Advanced Integrated Models (PV-AIM) Project. Biomedicines 2023; 11:1925. [PMID: 37509564 PMCID: PMC10377437 DOI: 10.3390/biomedicines11071925] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with polycythemia vera (PV) are at significant risk of thromboembolic events (TE). The PV-AIM study used the Optum® de-identified Electronic Health Record dataset and machine learning to identify markers of TE in a real-world population. Data for 82,960 patients with PV were extracted: 3852 patients were treated with hydroxyurea (HU) only, while 130 patients were treated with HU and then changed to ruxolitinib (HU-ruxolitinib). For HU-alone patients, the annualized incidence rates (IR; per 100 patients) decreased from 8.7 (before HU) to 5.6 (during HU) but increased markedly to 10.5 (continuing HU). Whereas for HU-ruxolitinib patients, the IR decreased from 10.8 (before HU) to 8.4 (during HU) and was maintained at 8.3 (after switching to ruxolitinib). To better understand markers associated with TE risk, we built a machine-learning model for HU-alone patients and validated it using an independent dataset. The model identified lymphocyte percentage (LYP), neutrophil percentage (NEP), and red cell distribution width (RDW) as key markers of TE risk, and optimal thresholds for these markers were established, from which a decision tree was derived. Using these widely used laboratory markers, the decision tree could be used to identify patients at high risk for TE, facilitate treatment decisions, and optimize patient management.
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Affiliation(s)
- Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ivan Krečak
- Department of Internal Medicine, General Hospital of Sibenik-Knin County, 22000 Sibenik, Croatia
- Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
| | - Florian H. Heidel
- Hematology, Oncology, Stem Cell Transplantation and Palliative Care, Internal Medicine C, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Valerio De Stefano
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica, Fondazione Policlinico A. Gemelli IRCCS, 00168 Roma, Italy
| | - Kenneth Bryan
- Novartis Ireland Limited, Dublin 4, D04 A9N6 Dublin, Ireland
| | | | | | | | - Aoife Smyth
- Novartis Pharma AG, CH-4056 Basel, Switzerland
- Novartis Pharmaceuticals UK Limited, London W12 7FQ, UK
| | | | - Erwan Bigan
- The Boston Consulting Group, Boston, MA 02210, USA
| | - Michael Ruhl
- The Boston Consulting Group, Boston, MA 02210, USA
| | | | - Magali Beffy
- The Boston Consulting Group, Boston, MA 02210, USA
| | - Jean-Jacques Kiladjian
- Centre d’Investigations Cliniques (INSERM CIC 1427), Université de Paris, Hôpital Saint-Louis, AP-HP, 75010 Paris, France
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Leiva O, Hobbs G. Author's reply. J Cardiol 2023; 81:587-588. [PMID: 36681318 DOI: 10.1016/j.jjcc.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Krečak I, Pivac L, Lucijanić M, Skelin M. Polypharmacy, Potentially Inappropriate Medications, and Drug-to-Drug Interactions in Patients with Chronic Myeloproliferative Neoplasms. Biomedicines 2023; 11:biomedicines11051301. [PMID: 37238972 DOI: 10.3390/biomedicines11051301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
Polypharmacy, potentially inappropriate medications (PIMs), and drug-to-drug interactions (DDIs) are highly prevalent in the elderly and may have adverse effects on health-related outcomes. Their occurrence and clinical and prognostic associations in patients with chronic myeloproliferative neoplasms (MPN) are unknown. We retrospectively evaluated polypharmacy, PIMs, and DDIs in a cohort of 124 MPN patients (essential thrombocythemia, ET = 63, polycythemia vera, PV = 44, myelofibrosis = 9, MPN unclassifiable = 8) from a single community hematology practice. There were 761 drug prescriptions with a median of five prescribed medications per patient. Polypharmacy, at least one PIM (calculated for persons >60 years of age, n = 101), and at least one DDI were recorded in 76 (61.3%), 46 (45.5%), and 77 (62.1%) of patients, respectively. Seventy-four (59.6%) and twenty-one (16.9%) patients had at least one C or at least one D interaction, respectively. Among other associations, polypharmacy and DDIs were associated with older age, management of disease-related symptoms, osteoarthritis/osteoporosis, and different CV disorders. In multivariate analyses adjusted for clinically meaningful parameters, both polypharmacy and DDIs were significantly associated with inferior overall survival (OS) and time to thrombosis (TTT), whereas PIMs had no significant associations with neither OS nor TTT. There were no associations with bleeding or transformation risks. Polypharmacy, DDIs, and PIMs are very frequent among MPN patients and may have important clinical associations.
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Affiliation(s)
- Ivan Krečak
- Department of Internal Medicine, General Hospital of Sibenik-Knin County, 22000 Sibenik, Croatia
- Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
| | - Ljerka Pivac
- Pharmacy Department, University Hospital Center Split, 21000 Split, Croatia
| | - Marko Lucijanić
- Divison of Hematology, University Hospital Dubrava, 10000 Zagreb, Croatia
- Faculty of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Marko Skelin
- Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
- Pharmacy Department, General Hospital of Sibenik-Knin County, 22000 Sibenik, Croatia
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Krecak I, Skelin M, Verstovsek S. Evaluating ropeginterferon alfa-2b for the treatment of adults with polycythemia vera. Expert Rev Hematol 2023; 16:305-316. [PMID: 37002907 DOI: 10.1080/17474086.2023.2199151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Interferons (IFNs) have been used for decades to treat polycythemia vera (PV). Single-arm clinical trials assessing IFN in PV patients demonstrated high hematological and molecular response rates, indicating potential disease-modifying activity of IFN. However, discontinuation rates of IFNs have been rather high due to frequent treatment-related side-effects. AREAS COVERED Ropeginterferon alfa-2b (ROPEG) is a monopegylated IFN consisting of a single isoform, which differentiates it from previous IFNs with respect to tolerability and dosing frequency. ROPEG has improved pharmacokinetic and pharmacodynamic properties, which allow extended dosing every 2 weeks and monthly administration during maintenance phase. This review covers ROPEG's pharmacokinetic and pharmacodynamic properties, presents results of randomized clinical trials (RCT) that evaluated ROPEG in the treatment of PV patients, and discusses contemporary findings regarding the potential disease-modifying activity of ROPEG. EXPERT OPINION RCT have demonstrated high rates of hematological and molecular responses in PV patients treated with ROPEG, irrespective of thrombotic risk. Drug discontinuation rates were generally low. However, even though RCT captured the most important surrogate endpoints of thrombotic risk and disease progression in PV, they were not statistically powered to fully determine whether therapeutic intervention with ROPEG indeed has a direct positive effect on these important clinical outcomes.
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Affiliation(s)
- Ivan Krecak
- Department of Internal Medicine, General Hospital of Sibenik-Knin County, Sibenik, Croatia
- Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Marko Skelin
- Faculty of Medicine, University of Rijeka, Rijeka, Croatia
- Pharmacy Department, General Hospital of Šibenik-Knin County, Šibenik, Croatia
| | - Srdan Verstovsek
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas, USA
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Krecak I, Lucijanic M, Verstovsek S. Advances in Risk Stratification and Treatment of Polycythemia Vera and Essential Thrombocythemia. Curr Hematol Malig Rep 2022; 17:155-169. [PMID: 35932395 DOI: 10.1007/s11899-022-00670-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Estimating and modifying thrombotic risk is currently the mainstay of care for patients with polycythemia vera (PV) and essential thrombocythemia (ET). In recent years, however, increased attention has shifted towards quality of life and disease modification. In this review, we discuss recent advances in risk stratification, present updated results for ruxolitinib and interferon randomized clinical trials, discuss new approaches in antiplatelet and anticoagulant treatment, and summarize early phase trials of novel agents and emerging therapeutic concepts for the treatment of PV and ET. RECENT FINDINGS International collaborations and novel technologies, i.e., next-generation sequencing and machine learning techniques, have demonstrated excellent abilities to improve thrombotic risk stratification in PV and ET. Updated results from ruxolitinib and interferon randomized clinical trials have confirmed excellent efficacy and safety of these agents, both as first- and second-line treatments. Early trials of novel agents (histone deacetylase inhibitors, telomerase inhibitors, lysine-specific demethylase-1 inhibitors, human double-minute 2 inhibitors, and hepcidin mimetics) have shown encouraging efficacy and safety in blood count control, reduction of splenomegaly, and alleviation of disease-related symptoms. Finally, accumulating evidence suggested that direct oral anticoagulants may be a valid therapeutic alternative to warfarin for prolonged thromboprophylaxis. International collaborations ("big data") with the help of new technologies represent an exciting new approach to analyze rare outcomes in rare diseases, especially for identifying novel prognostic biomarkers in PV and ET. Randomized clinical trials are also needed to fully elucidate whether novel agents may establish new standards of care.
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Affiliation(s)
- Ivan Krecak
- Department of Internal Medicine, General Hospital of Sibenik-Knin County, Stjepana Radića 83, 22000, Sibenik, Croatia. .,School of Medicine, University of Rijeka, Rijeka, Croatia.
| | - Marko Lucijanic
- Division of Hematology, University Hospital Dubrava, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Srdan Verstovsek
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
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Kwon SS, Yoon SY, Jeong SY, Lee MY, Kim KH, Lee N, Won JH. Neutrophil-lymphocyte ratio and carotid plaque burden in patients with essential thrombocythemia and polycythemia vera. Nutr Metab Cardiovasc Dis 2022; 32:1913-1916. [PMID: 35606226 DOI: 10.1016/j.numecd.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND AIMS Chronic inflammation plays a critical role in the pathogenesis of myeloproliferative neoplasm (MPN), and inflammatory conditions are closely related to the development and exacerbation of atherosclerosis. This study aimed to compare carotid plaque burden and neutrophil-lymphocyte ratio (NLR) in the essential thrombocythemia (ET)/polycythemia vera (PV) and control groups. METHODS AND RESULTS We retrospectively assessed carotid plaque burden and NLR in patients with ET/PV between January 2010 and September 2021 and propensity-score matched these patients to control subjects from the general population. All patients underwent carotid imaging using carotid ultrasonography for atherosclerosis screening. After 3:1 propensity-score matching, 140 patients in the control group were matched to 51 patients in ET/PV group. The mean NLR was significantly higher in the MPN group than in the control group (4.77 ± 3.96 vs. 1.93 ± 1.03, p < 0.001). The carotid plaque score was also higher in MPN group than in the control group (2.37 ± 1.47 vs. 1.94 ± 1.17, p = 0.038). CONCLUSION Patients with PV/ET show a higher NLR and carotid plaque burden than the normal population. This reflected that PV/ET was a highly inflammatory and atherosclerotic condition expressing potentially increased cardiovascular risk.
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Affiliation(s)
- Seong Soon Kwon
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Seug Yun Yoon
- Division of Hematology & Medical Oncology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Sun Young Jeong
- Division of Hematology & Medical Oncology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Min-Young Lee
- Division of Hematology & Medical Oncology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Kyoung-Ha Kim
- Division of Hematology & Medical Oncology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Namsu Lee
- Division of Hematology & Medical Oncology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Jong-Ho Won
- Division of Hematology & Medical Oncology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.
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Rippel N, Tremblay D, Zubizarreta N, Podoltsev N, Gotlib J, Heaney M, Kuykendall A, O'Connell C, Shammo JM, Fleischman A, Kremyanskaya M, Hoffman R, Mesa R, Yacoub A, Mascarenhas J. Anagrelide for platelet-directed cytoreduction in polycythemia vera: Insights into utility and safety outcomes from a large multi-center database. Leuk Res 2022; 119:106903. [PMID: 35717689 DOI: 10.1016/j.leukres.2022.106903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
Abstract
Anagrelide (ANA) is a platelet-specific cytoreductive agent utilized in the guideline-directed management of high-risk essential thrombocythemia. In the context of polycythemia vera (PV), ANA is occasionally employed in clinical practice, although data has not consistently demonstrated a benefit to targeting a platelet goal as a therapeutic endpoint. The aim of the current study was to delineate the patterns of ANA use in PV, and to describe outcomes and toxicities. Within a multi-center cohort of 527 patients with PV, 48 received ANA (9 excluded for absent data). 27 (69.2%) had high-risk PV, 10 (25.6%) had prior thrombosis, and none had extreme thrombocytosis, acquired von Willebrand disease, and/or documented resistance to hydroxyurea. While ANA effectively lowered median platelet count, 43.5% of patients had an unresolved thrombocytosis at time of ANA discontinuation. Treatment-emergent adverse events-including headaches, cardiac palpitations and arrhythmias, nausea, vomiting and/or diarrhea-led to ANA discontinuation in 76.9% of patients. Further, three patients experienced arterial thromboses during a median duration of 27.5 months of ANA therapy. In conclusion, this study highlights ANA's restrictive tolerability profile which, compounded by the absence of clear advantage to strict platelet control in PV, suggests the use of ANA should be limited in this setting.
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Affiliation(s)
- Noa Rippel
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute, New York, NY, USA
| | - Nikolai Podoltsev
- Hematology Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jason Gotlib
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA, USA
| | - Mark Heaney
- Columbia University Medical Center, New York, NY, USA
| | | | - Casey O'Connell
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Jamile M Shammo
- Department of Internal Medicine, Division of Hematology/Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Angela Fleischman
- Irvine Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, CA, USA
| | - Marina Kremyanskaya
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ronald Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- Department of Hematology and Oncology, Mays MD Anderson Cancer Center at UT Health San Antonio, San Antonio, TX, USA
| | | | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Carobbio A, Vannucchi AM, De Stefano V, Masciulli A, Guglielmelli P, Loscocco GG, Ramundo F, Rossi E, Kanthi Y, Tefferi A, Barbui T. Neutrophil-to-lymphocyte ratio is a novel predictor of venous thrombosis in polycythemia vera. Blood Cancer J 2022; 12:28. [PMID: 35145055 PMCID: PMC8831521 DOI: 10.1038/s41408-022-00625-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/21/2022] [Accepted: 01/26/2022] [Indexed: 11/09/2022] Open
Abstract
We investigated the neutrophil-to-lymphocyte ratio (NLR) as a predictor of thrombosis in polycythemia vera (PV). After a median follow-up of 2.51 years, of 1508 PV patients enrolled in the ECLAP study, 82 and 84 developed arterial and venous thrombosis, respectively. Absolute counts of total leukocytes, neutrophils, lymphocytes, platelets, and the NLR were tested by generalized additive models (GAM) to evaluate their trend in continuous scale of thrombotic risk. Only for venous thrombosis, we showed that baseline absolute neutrophil and lymphocyte counts were on average respectively higher (median: 6.8 × 109/L, p = 0.002) and lower (median: 1.4 × 109/L, p = 0.001), leading to increased NLR values (median: 5.1, p = 0.002). In multivariate analysis, the risk of venous thrombosis was independently associated with previous venous events (HR = 5.48, p ≤ 0.001) and NLR values ≥5 (HR = 2.13, p = 0.001). Moreover, the relative risk in both low- and high-standard risk groups was almost doubled in the presence of NLR ≥ 5. These findings were validated in two Italian independent external cohorts (Florence, n = 282 and Rome, n = 175) of contemporary PV patients. Our data support recent experimental work that venous thrombosis is controlled by innate immune cells and highlight that NLR is an inexpensive and easily accessible prognostic biomarker of venous thrombosis.
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Affiliation(s)
| | - 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
| | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Arianna Masciulli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - 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
| | - Giuseppe Gaetano Loscocco
- Center Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Department of Experimental and Clinical Medicine, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Francesco Ramundo
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Elena Rossi
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | | | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
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Pemmaraju N, Gerds AT, Yu J, Parasuraman S, Shah A, Xi A, Kumar S, Scherber RM, Verstovsek S. Thrombotic events and mortality risk in patients with newly diagnosed polycythemia vera or essential thrombocythemia. Leuk Res 2022; 115:106809. [DOI: 10.1016/j.leukres.2022.106809] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
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Krečak I, Morić Perić M, Zekanović I, Holik H, Coha B, Gverić-Krečak V, Lucijanić M. No Impact of the Increased Number of Cardiovascular Risk Factors on Thrombosis and Survival in Polycythemia Vera. Oncol Res Treat 2021; 44:201-203. [PMID: 33503631 DOI: 10.1159/000514347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/11/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Ivan Krečak
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia,
| | | | - Ivan Zekanović
- Department of Internal Medicine, General Hospital of Zadar, Zadar, Croatia
| | - Hrvoje Holik
- Dr. Josip Benčević General Hospital, Slavonski Brod, Croatia
| | - Božena Coha
- Dr. Josip Benčević General Hospital, Slavonski Brod, Croatia
| | - Velka Gverić-Krečak
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia
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