51
|
The Role of Reactive Oxygen Species in Myelofibrosis and Related Neoplasms. Mediators Inflamm 2015; 2015:648090. [PMID: 26538833 PMCID: PMC4619981 DOI: 10.1155/2015/648090] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/09/2015] [Indexed: 12/13/2022] Open
Abstract
Reactive oxygen species (ROS) have been implicated in a wide variety of disorders ranging between traumatic, infectious, inflammatory, and malignant diseases. ROS are involved in inflammation-induced oxidative damage to cellular components including regulatory proteins and DNA. Furthermore, ROS have a major role in carcinogenesis and disease progression in the myeloproliferative neoplasms (MPNs), where the malignant clone itself produces excess of ROS thereby creating a vicious self-perpetuating circle in which ROS activate proinflammatory pathways (NF-κB) which in turn create more ROS. Targeting ROS may be a therapeutic option, which could possibly prevent genomic instability and ultimately myelofibrotic and leukemic transformation. In regard to the potent efficacy of the ROS-scavenger N-acetyl-cysteine (NAC) in decreasing ROS levels, it is intriguing to consider if NAC treatment might benefit patients with MPN. The encouraging results from studies in cystic fibrosis, systemic lupus erythematosus, and chronic obstructive pulmonary disease warrant such studies. In addition, the antioxidative potential of the widely used agents, interferon-alpha2, statins, and JAK inhibitors, should be investigated as well. A combinatorial approach using old agents with anticancer properties together with novel JAK1/2 inhibitors may open a new era for patients with MPNs, the outlook not only being “minimal residual disease” and potential cure but also a marked improvement in inflammation-mediated comorbidities.
Collapse
|
52
|
Springuel L, Renauld JC, Knoops L. JAK kinase targeting in hematologic malignancies: a sinuous pathway from identification of genetic alterations towards clinical indications. Haematologica 2015; 100:1240-53. [PMID: 26432382 PMCID: PMC4591756 DOI: 10.3324/haematol.2015.132142] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/17/2015] [Indexed: 12/16/2022] Open
Abstract
Constitutive JAK-STAT pathway activation occurs in most myeloproliferative neoplasms as well as in a significant proportion of other hematologic malignancies, and is frequently a marker of poor prognosis. The underlying molecular alterations are heterogeneous as they include activating mutations in distinct components (cytokine receptor, JAK, STAT), overexpression (cytokine receptor, JAK) or rare JAK2 fusion proteins. In some cases, concomitant loss of negative regulators contributes to pathogenesis by further boosting the activation of the cascade. Exploiting the signaling bottleneck provided by the limited number of JAK kinases is an attractive therapeutic strategy for hematologic neoplasms driven by constitutive JAK-STAT pathway activation. However, given the conserved nature of the kinase domain among family members and the interrelated roles of JAK kinases in many physiological processes, including hematopoiesis and immunity, broad usage of JAK inhibitors in hematology is challenged by their narrow therapeutic window. Novel therapies are, therefore, needed. The development of more selective inhibitors is a questionable strategy as such inhibitors might abrogate the beneficial contribution of alleviating the cancer-related pro-inflammatory microenvironment and raise selective pressure to a threshold that allows the emergence of malignant subclones harboring drug-resistant mutations. In contrast, synergistic combinations of JAK inhibitors with drugs targeting cascades that work in concert with JAK-STAT pathway appear to be promising therapeutic alternatives to JAK inhibitors as monotherapies.
Collapse
Affiliation(s)
- Lorraine Springuel
- de Duve Institute, Université Catholique de Louvain, Brussels, Belgium Ludwig Institute for Cancer Research, Brussels, Belgium
| | - Jean-Christophe Renauld
- de Duve Institute, Université Catholique de Louvain, Brussels, Belgium Ludwig Institute for Cancer Research, Brussels, Belgium
| | - Laurent Knoops
- de Duve Institute, Université Catholique de Louvain, Brussels, Belgium Ludwig Institute for Cancer Research, Brussels, Belgium Hematology Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
53
|
|
54
|
McLornan DP, Khan AA, Harrison CN. Immunological Consequences of JAK Inhibition: Friend or Foe? Curr Hematol Malig Rep 2015. [PMID: 26292803 DOI: 10.1007/s11899-015-0284-z.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Over the last decade, unparalleled advances have been made within the field of 'Philadelphia chromosome'-negative myeloproliferative neoplasms (MPN) regarding both disease pathogenesis and therapeutic targeting. The discovery of deregulated JAK-STAT signalling in MPN led to the rapid development of JAK inhibitor agents, targeting both mutated and wild-type JAK, which have significantly altered the therapeutic paradigm for patients with MPN. Although the largest population treated with these agents incorporates those with myelofibrosis, increasing data supports potential usage in other MPNs such as essential thromocythaemia and polycythaemia vera. Many MPNs are associated with a hyperinflammatory state and deregulation of immune homeostasis. Over the last few years, research has focused on attempting to decipher the complex and context-dependent changes that contribute to this immune deregulation. Moreover, very recent studies have demonstrated significant JAK inhibitor-mediated effects within the T cell, natural killer cell and dendritic cell compartments following exposure to JAK inhibitors. In parallel, case reports of infections occurring following exposure to ruxolitinib, many of which are atypical, have focused research efforts on delineating JAK inhibitor-associated immunological consequences. Within this review article, we will describe what is currently known about MPN-associated immune deregulation and JAK inhibitor-mediated immunomodulation.
Collapse
Affiliation(s)
- Donal P McLornan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH, UK. .,Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, SE5 9NU, UK.
| | - Alesia A Khan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Claire N Harrison
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| |
Collapse
|
55
|
McLornan DP, Khan AA, Harrison CN. Immunological Consequences of JAK Inhibition: Friend or Foe? Curr Hematol Malig Rep 2015; 10:370-9. [PMID: 26292803 DOI: 10.1007/s11899-015-0284-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Donal P McLornan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, SE5 9NU, UK.
| | - Alesia A Khan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| | - Claire N Harrison
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH, UK
| |
Collapse
|
56
|
Duenas-Perez AB, Mead AJ. Clinical potential of pacritinib in the treatment of myelofibrosis. Ther Adv Hematol 2015; 6:186-201. [PMID: 26288713 DOI: 10.1177/2040620715586527] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Myelofibrosis (MF) is a myeloid disorder caused by a clonal hematopoietic stem-cell proliferation associated with activation of the Janus kinase (JAK) signal transducer and activator of transcription (STAT) signaling pathways. Patients with MF often develop severe splenomegaly, marked symptom burden and significant cytopenias, with a consequent marked negative impact on quality of life and survival. The management of MF patients has dramatically improved with the development of a group of drugs that inhibit JAK signaling. The first of these agents to be approved was ruxolitinib, a JAK1/JAK2 inhibitor, which has been shown to improve both spleen size and symptoms in patients with MF. However, myelotoxicity, particularly of the platelet lineage, significantly limits the patient population who can benefit from this agent. Thus, there is an unmet need for novel agents with limited myelotoxicity to treat MF. Pacritinib, a JAK2 and FMS-like tyrosine kinase 3 (FLT3) inhibitor, has shown promising results in early phase trials with limited myelotoxicity and clinical responses that are comparable with those seen with ruxolitinib, even in patients with severe thrombocytopenia. Currently there are two large phase III clinical trials of pacritinib in MF, including patients with thrombocytopenia, and those previously treated with ruxolitinib. If the encouraging results observed in early phase clinical trials are confirmed, pacritinib will represent a new and exciting treatment option for patients with MF and particularly patients with significant cytopenias.
Collapse
Affiliation(s)
- Ana B Duenas-Perez
- Haematopoietic Stem Cell Biology, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Adam J Mead
- Haematopoietic Stem Cell Biology, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford OX3 9DS, UK
| |
Collapse
|
57
|
Specificity of JAK-kinase inhibition determines impact on human and murine T-cell function. Leukemia 2015; 30:991-5. [PMID: 26242463 DOI: 10.1038/leu.2015.218] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
58
|
Chen YY, Huang CE, Lee KD, Chen CC. Clinical efficacy and safety of ruxolitinib in the management of myelofibrosis: A single institution experience in Taiwan. Hematology 2015. [DOI: 10.1179/1607845415y.0000000036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Yi-Yang Chen
- Division of Hematology and Oncology, Department of Medicine, Chiayi Chang Gung Memorial Hospital, Taiwan
| | - Cih-En Huang
- Division of Hematology and Oncology, Department of Medicine, Chiayi Chang Gung Memorial Hospital, Taiwan
| | - Kuan-Der Lee
- Division of Hematology and Oncology, Department of Medicine, Chiayi Chang Gung Memorial Hospital, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan, Taiwan
| | - Chih-Cheng Chen
- Division of Hematology and Oncology, Department of Medicine, Chiayi Chang Gung Memorial Hospital, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan, Taiwan
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| |
Collapse
|
59
|
Pálmason R, Lindén O, Richter J. Case-report: EBV driven lymphoproliferative disorder associated with Ruxolitinib. BMC HEMATOLOGY 2015; 15:10. [PMID: 26167286 PMCID: PMC4498562 DOI: 10.1186/s12878-015-0029-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 05/12/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ruxolitinib, a novel inhibitor of Janus kinases 1 and 2, was recently approved for the treatment of myelofibrosis but, recently, attention has been drawn to potential side effects and especially opportunistic infections and virus reactivations. EBV reactivation has not previously been reported to occur in association with Ruxolitinib. CASE PRESENTATION We report a case of a 57 year old female with post-polycythemic myelofibrosis who was treated with Ruxolitinib. Approximately 9 weeks later she presented with a rapidly fatal, suspected EBV driven lymphoproliferative disorder in the CNS. CONCLUSIONS Our report further underlines that patients treated with Ruxolitinib should be monitored closely for reactivations of opportunistic pathogens and viral infections.
Collapse
Affiliation(s)
- Róbert Pálmason
- />Department of Hematology and vascular disorders, Skåne University Hospital, Lund, Sweden
- />Lund University, Lund, Sweden
| | - Ola Lindén
- />Department of Oncology, Skåne University Hospital, Lund, Sweden
- />Lund University, Lund, Sweden
| | - Johan Richter
- />Department of Hematology and vascular disorders, Skåne University Hospital, Lund, Sweden
- />Lund University, Lund, Sweden
| |
Collapse
|
60
|
Keohane C, Kordasti S, Seidl T, Perez Abellan P, Thomas NSB, Harrison CN, McLornan DP, Mufti GJ. JAK inhibition induces silencing of T Helper cytokine secretion and a profound reduction in T regulatory cells. Br J Haematol 2015; 171:60-73. [DOI: 10.1111/bjh.13519] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/24/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Clodagh Keohane
- Department of Haematology; Guy's and St Thomas’ NHS Foundation Trust; London UK
- Department of Haematological Medicine; Kings College London; London UK
| | - Shahram Kordasti
- Department of Haematological Medicine; Kings College London; London UK
- Department of Haematological Medicine; Kings College Hospital NHS Foundation Trust; London UK
| | - Thomas Seidl
- Department of Haematological Medicine; Kings College London; London UK
| | | | | | - Claire N. Harrison
- Department of Haematology; Guy's and St Thomas’ NHS Foundation Trust; London UK
| | - Donal P. McLornan
- Department of Haematology; Guy's and St Thomas’ NHS Foundation Trust; London UK
- Department of Haematological Medicine; Kings College Hospital NHS Foundation Trust; London UK
| | - Ghulam J. Mufti
- Department of Haematological Medicine; Kings College London; London UK
- Department of Haematological Medicine; Kings College Hospital NHS Foundation Trust; London UK
| |
Collapse
|
61
|
Schönberg K, Rudolph J, Vonnahme M, Parampalli Yajnanarayana S, Cornez I, Hejazi M, Manser AR, Uhrberg M, Verbeek W, Koschmieder S, Brümmendorf TH, Brossart P, Heine A, Wolf D. JAK Inhibition Impairs NK Cell Function in Myeloproliferative Neoplasms. Cancer Res 2015; 75:2187-99. [PMID: 25832652 DOI: 10.1158/0008-5472.can-14-3198] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/04/2015] [Indexed: 11/16/2022]
Abstract
Ruxolitinib is a small-molecule inhibitor of the JAK kinases, which has been approved for the treatment of myelofibrosis, a rare myeloproliferative neoplasm (MPN), but clinical trials are also being conducted in inflammatory-driven solid tumors. Increased infection rates have been reported in ruxolitinib-treated patients, and natural killer (NK) cells are immune effector cells known to eliminate both virus-infected and malignant cells. On this basis, we sought to compare the effects of JAK inhibition on human NK cells in a cohort of 28 MPN patients with or without ruxolitinib treatment and 24 healthy individuals. NK cell analyses included cell frequency, receptor expression, proliferation, immune synapse formation, and cytokine signaling. We found a reduction in NK cell numbers in ruxolitinib-treated patients that was linked to the appearance of clinically relevant infections. This reduction was likely due to impaired maturation of NK cells, as reflected by an increased ratio in immature to mature NK cells. Notably, the endogenous functional defect of NK cells in MPN was further aggravated by ruxolitinib treatment. In vitro data paralleled these in vivo results, showing a reduction in cytokine-induced NK cell activation. Further, reduced killing activity was associated with an impaired capacity to form lytic synapses with NK target cells. Taken together, our findings offer compelling evidence that ruxolitinib impairs NK cell function in MPN patients, offering an explanation for increased infection rates and possible long-term side effects associated with ruxolitinib treatment.
Collapse
Affiliation(s)
- Kathrin Schönberg
- Medical Clinic, Oncology, Hematology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | - Janna Rudolph
- Medical Clinic, Oncology, Hematology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | - Maria Vonnahme
- Medical Clinic, Oncology, Hematology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | | | - Isabelle Cornez
- Medical Clinic, Oncology, Hematology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | - Maryam Hejazi
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Clinic Düsseldorf, Düsseldorf, Germany
| | - Angela R Manser
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Clinic Düsseldorf, Düsseldorf, Germany
| | - Markus Uhrberg
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Clinic Düsseldorf, Düsseldorf, Germany
| | | | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Peter Brossart
- Medical Clinic, Oncology, Hematology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | - Annkristin Heine
- Medical Clinic, Oncology, Hematology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany
| | - Dominik Wolf
- Medical Clinic, Oncology, Hematology and Rheumatology, University Clinic Bonn (UKB), Bonn, Germany.
| |
Collapse
|
62
|
Barosi G, Rosti V, Gale RP. Critical appraisal of the role of ruxolitinib in myeloproliferative neoplasm-associated myelofibrosis. Onco Targets Ther 2015; 8:1091-102. [PMID: 26056473 PMCID: PMC4445786 DOI: 10.2147/ott.s31916] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The recent approval of molecular-targeted therapies for myeloproliferative neoplasm-associated myelofibrosis (MPN-MF) has dramatically changed its therapeutic landscape. Ruxolitinib, a JAK1/JAK2 tyrosine kinase inhibitor, is now widely used for first- and second-line therapy in persons with MPN-MF, especially those with disease-related splenomegaly, intermediate- or high-risk disease, and constitutional symptoms. The goal of this work is to critically analyze data supporting use of ruxolitinib in the clinical settings approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA). We systematically reviewed the literature and analyzed the risk of biases in the two randomized studies (COMFORT I and COMFORT II) on which FDA and EMA approval was based. Our strategy was to apply the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach by evaluating five dimensions of evidence: (1) overall risk of bias, (2) imprecision, (3) inconsistency, (4) indirectness, and (5) publication bias. Based on these criteria, we downgraded the evidence from the COMFORT I and COMFORT II trials for performance, attrition, and publication bias. In the disease-associated splenomegaly sphere, we upgraded the quality of evidence because of large effect size but downgraded it because of comparator choice and outcome indirectness (quality of evidence, low). In the sphere of treating persons with intermediate- or high-risk disease, we downgraded the evidence because of imprecision in effect size measurement and population indirectness. In the sphere of disease-associated symptoms, we upgraded the evidence because of the large effect size, but downgraded it because of comparator indirectness (quality of evidence, moderate). In conclusion, using the GRADE technique, we identified factors affecting the quality of evidence that were otherwise unstated. Identifying and evaluating these factors should influence the confidence with which physicians use ruxolitinib in persons with MPN-MF.
Collapse
Affiliation(s)
- Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - Vittorio Rosti
- Center for the Study of Myelofibrosis, IRCCS Policlinico S Matteo Foundation, Pavia, Italy
| | - Robert Peter Gale
- Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, UK
| |
Collapse
|
63
|
Abstract
Myelofibrosis (MF), including primary, post-essential thrombocythemia and post-polycythemia vera MF, associates with a reduced quality of life and shortened life expectancy. Dysregulation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway is prominent, even in the absence of the JAK2(V617F) mutation. Therefore, all symptomatic MF patients may potentially derive benefit from JAK inhibitors. Despite the efficacy of JAK inhibitors in controlling signs and symptoms of MF, they do not eradicate the disease. Therefore, JAK inhibitors are currently being tested in combination with other novel therapies, a strategy which may be more effective in reducing disease burden, either by overcoming JAK inhibitor resistance or targeting additional mechanisms of pathogenesis. Additional targets include modulators of epigenetic regulation, pathways that work downstream from JAK/STAT (i.e. mammalian target of rapamycin/AKT/phosphoinositide 3-kinase) heat shock protein 90, hedgehog signaling, pro-fibrotic factors, abnormal megakaryocytes and telomerase. In this review, we discuss novel MF therapeutic strategies.
Collapse
Affiliation(s)
- Brady L Stein
- a Northwestern University Feinberg School of Medicine , Chicago , IL , USA
- b Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago , IL , USA
| | - Francisco Cervantes
- c Hospital Clínic, Hematology Department, Institut d'Investigació Biomédica August Pi i Sunyer , University of Barcelona , Barcelona , Spain
| | - Francis Giles
- b Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago , IL , USA
| | - Claire N Harrison
- d Department of Haematology , Guy's and St. Thomas' National Health Service Foundation Trust , London , UK
| | - Srdan Verstovsek
- e Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| |
Collapse
|
64
|
|
65
|
Pardanani A, Tefferi A. Definition and management of ruxolitinib treatment failure in myelofibrosis. Blood Cancer J 2014; 4:e268. [PMID: 25501025 PMCID: PMC4315890 DOI: 10.1038/bcj.2014.84] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 10/10/2014] [Indexed: 12/11/2022] Open
Abstract
Ruxolitinib, a Janus kinase (JAK)-1 and JAK-2 inhibitor, is the first-in-class drug to be licensed in the United States for the treatment of high- and intermediate-risk myelofibrosis (MF). Several other JAK inhibitors are in development with some currently undergoing phase-3 clinical trial testing. None of the currently available JAK inhibitors are specific to mutant JAK2; their mechanism of action involves attenuation of JAK-STAT signaling with downregulation of proinflammatory cytokines, rather than selective suppression of the disease clone. Accordingly, while ruxolitinib and other JAK inhibitors are effective in controlling splenomegaly and alleviating constitutional symptoms, their benefit in terms of reversing bone marrow fibrosis or inducing complete or partial remissions appears to be limited. The experience to date with ruxolitinib shows that despite its salutary effects on quality of life, over half of the patients discontinue treatment within 2-3 years. In the current perspective, we examine the incidence and causes of ruxolitinib 'treatment failure' in MF patients based on our personal experience as well as a review of the published literature. We also discuss the challenges in defining and classifying ruxolitinib failure, and within the context of several clinical scenarios, we provide recommendations for the post-ruxolitinib management of MF patients.
Collapse
Affiliation(s)
- A Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - A Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
66
|
Harrison CN, McMullin MF. Update in the myeloproliferative neoplasms. Clin Med (Lond) 2014; 14 Suppl 6:s66-70. [PMID: 25468923 DOI: 10.7861/clinmedicine.14-6-s66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The differential diagnosis of haematological abnormalities, such as leucocytosis, erythocytosis, thrombocytosis or indeed anaemia, is wide and disarming. Here we report on significant updates in the differential diagnosis of erythrocyosis and thrombocytosis presenting a simplified schema for the clinician. We then move to discuss significant advances in this field which have followed a series of key molecular findings, most specifically those affecting the JAK/STAT pathway.
Collapse
|
67
|
Chen YH, Lee CH, Pei SN. Pulmonary tuberculosis reactivation following ruxolitinib treatment in a patient with primary myelofibrosis. Leuk Lymphoma 2014; 56:1528-9. [DOI: 10.3109/10428194.2014.963082] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
68
|
Liew E, Lipton JH. Ruxolitinib for the treatment of disease-related splenomegaly or symptoms in adult patients with myelofibrosis. Int J Hematol Oncol 2014. [DOI: 10.2217/ijh.14.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Myelofibrosis is characterized by progressive splenomegaly, cytopenias and debilitating constitutional symptoms. It has the worst prognosis and poorest quality of life of all the chronic myeloproliferative neoplasms. Allogeneic stem cell transplantation is the only curative therapy, but it carries high treatment-related risks and is thus available to only a small subset of patients. All other interventions merely palliate either anemia or splenomegaly. Ruxolitinib, a JAK1/2 inhibitor, has recently been shown to be effective in reducing splenomegaly and improving constitutional symptoms to a degree that has not been achieved with conventional therapy. However, treatment with ruxolitinib can often worsen anemia, and its ability to change the natural history of myelofibrosis has not been definitively established.
Collapse
Affiliation(s)
- Elena Liew
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey H Lipton
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
69
|
Ruxolitinib-associated tuberculosis: a case of successful ruxolitinib rechallenge. Ann Hematol 2014; 94:519-20. [DOI: 10.1007/s00277-014-2183-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 08/03/2014] [Indexed: 10/24/2022]
|
70
|
Ferreira BV, Harrison C. How many JAK inhibitors in myelofibrosis? Best Pract Res Clin Haematol 2014; 27:187-95. [PMID: 25189729 DOI: 10.1016/j.beha.2014.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 07/11/2014] [Indexed: 01/13/2023]
Abstract
The discovery of the activating mutation JAK2 V617F ushered a new era in MPN which included new diagnostic and prognostic criteria as well as a potential therapeutic target. JAK2 inhibition became a reality with first patients receiving drugs that targeted JAK2 in 2007 and was marked by the first approval in 2011 of Ruxolitinib a JAK 1 and 2-inhibitor to treat myelofibrosis (MF). In this article entitled "How many JAK inhibitors for myelofibrosis" we discuss JAK2 as a target, review briefly the benefits to patients with MF of JAK inhibition and highlight some of the differences between the number of JAK inhibitors currently being evaluated. Reflecting upon what we have learnt from the chronic myeloid leukaemia field and for MF regarding disease complexity as well as individual patient factors including resistance we discuss why it is likely we will need several different agents with JAK inhibitory activity. The next chapter discusses combination therapies for myelofibrosis which is a logical step in both trying to cure this disease and improve patient outcome and toxicities with JAK inhibitors.
Collapse
Affiliation(s)
- Bruna Velosa Ferreira
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Claire Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| |
Collapse
|
71
|
Galli S, McLornan D, Harrison C. Safety evaluation of ruxolitinib for treating myelofibrosis. Expert Opin Drug Saf 2014; 13:967-76. [PMID: 24896661 DOI: 10.1517/14740338.2014.916273] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION In 2005, the JAK2 V617F mutation was identified and found to be highly prevalent in the 'Philadephia Chromosome-negative' Myeloproliferative neoplasms (MPN). This led to new diagnostic criteria for MPN in addition to the development of the first targeted therapy for myelofibrosis (MF), ruxolitinib . AREAS COVERED Ruxolitinib was approved within 5 years of 'first-in-man' trials; it has been assessed in two large Phase III trials, and to date, several thousand patients have been prescribed this drug. This article reviews the latest data from the Phase III trials concerning efficacy and safety in addition to post-authorisation data for this agent. Ruxolitinib is an extremely well-tolerated drug; it is associated with bruising, headaches, dizziness, anaemia and thrombocytopaenia. In addition, an augmented risk of infections has been documented. EXPERT OPINION Ruxolitinib has radically altered the therapeutic landscape for MF with demonstrated advantages over standard therapy, irrespective of JAK2 mutational status and a signal suggesting survival benefit. Other JAK inhibitors are also in late stages of development, although the furthest advanced has just been withdrawn due to cases of encephalopathy (not documented with ruxolitinib). This reminds the clinical community of the need for post-marketing surveillance of safety for these agents. Challenges ahead are identification of appropriate surrogates for survival benefit and perhaps how to best use ruxolitinib either alone or in combination with other therapies.
Collapse
Affiliation(s)
- Sofia Galli
- Guy's and St Thomas' NHS Foundation Trust , London , UK
| | | | | |
Collapse
|
72
|
Lee SC, Feenstra J, Georghiou PR. Pneumocystis jiroveci pneumonitis complicating ruxolitinib therapy. BMJ Case Rep 2014; 2014:bcr-2014-204950. [PMID: 24891492 DOI: 10.1136/bcr-2014-204950] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Ruxolitinib is a novel inhibitor of the Janus kinase (JAK) pathway that has become available for the treatment of myelofibrosis. There are increasing reports of opportunistic infections associated with ruxolitinib therapy. We present a case of Pneumocystis jiroveci pneumonitis complicating ruxolitinib therapy. Clinicians should consider the use of pneumocystis prophylaxis when using ruxolitinib.
Collapse
Affiliation(s)
- Samantha C Lee
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - John Feenstra
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia Department of Thoracic Medicine, The Wesley Hospital, Auchenflower, Queensland, Australia
| | - Paul R Georghiou
- Department of Infectious Diseases, The Wesley Hospital, Auchenflower, Queensland, Australia
| |
Collapse
|
73
|
Abstract
INTRODUCTION The discovery of the activating JAK2 V617F mutation in patients with myelofibrosis (MF) led to the development of JAK2 inhibitors. The first such inhibitor to enter clinical trials was ruxolitinib . This review summarizes preclinical and clinical data of ruxolitinib in MF. AREAS COVERED A literature search through Medline employing the terms 'ruxolitinib,' 'INCB018424' and 'myelofibrosis' was undertaken. The results from Phase I/II studies in patients with MF showed that ruxolitinib led to durable improvements in splenomegaly, and symptoms associated with MF. Two Phase III trials have compared ruxolitinib against placebo and best available therapy, and in both studies ruxolitinib demonstrated superior rates of spleen control and symptom improvement, and additional analysis demonstrated a survival benefit with ruxolitinib treatment. The main toxicities seen with ruxolitinib are cytopenias, which are managed with dose adjustments. Recent reports documented sporadic cases of immunosuppression-related infections. Ruxolitinib is the first drug ever approved for the therapy of patients with MF. EXPERT OPINION Understanding the factors that predict the rate and duration of response to ruxolitinib would improve our ability to manage patients treated with this medication. Clinical trials combining ruxolitinib with novel compounds that are also active in MF will further improve therapy for this disease.
Collapse
Affiliation(s)
- Fabio P S Santos
- Hospital Israelita Albert Einstein, Hematology and Oncology Center , São Paulo, SP , Brazil
| | | |
Collapse
|
74
|
|
75
|
JAK inhibition with ruxolitinib as pretreatment for allogeneic stem cell transplantation in primary or post-ET/PV myelofibrosis. Leukemia 2014; 28:1736-8. [PMID: 24569777 DOI: 10.1038/leu.2014.86] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
76
|
Ruxolitinib is a potent immunosuppressive compound: is it time for anti-infective prophylaxis? Blood 2013; 122:3843-4. [DOI: 10.1182/blood-2013-10-531103] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
77
|
Hepatitis B virus reactivation associated with ruxolitinib. Ann Hematol 2013; 93:1075-6. [PMID: 24173089 DOI: 10.1007/s00277-013-1936-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 10/08/2013] [Indexed: 01/24/2023]
|
78
|
Massa M, Rosti V, Campanelli R, Fois G, Barosi G. Rapid and long-lasting decrease of T-regulatory cells in patients with myelofibrosis treated with ruxolitinib. Leukemia 2013; 28:449-51. [PMID: 24145312 DOI: 10.1038/leu.2013.296] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- M Massa
- Biotechnology Research Area, IRCCS Policliico S. Matteo Foundation, Pavia, Italy
| | - V Rosti
- 1] Biotechnology Research Area, IRCCS Policliico S. Matteo Foundation, Pavia, Italy [2] Center for the Study of Myelofibrosis, Biotechnology Research Area, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - R Campanelli
- 1] Biotechnology Research Area, IRCCS Policliico S. Matteo Foundation, Pavia, Italy [2] Center for the Study of Myelofibrosis, Biotechnology Research Area, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - G Fois
- 1] Biotechnology Research Area, IRCCS Policliico S. Matteo Foundation, Pavia, Italy [2] Center for the Study of Myelofibrosis, Biotechnology Research Area, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - G Barosi
- 1] Biotechnology Research Area, IRCCS Policliico S. Matteo Foundation, Pavia, Italy [2] Center for the Study of Myelofibrosis, Biotechnology Research Area, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| |
Collapse
|