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TIDEL-II: first-line use of imatinib in CML with early switch to nilotinib for failure to achieve time-dependent molecular targets. Blood 2014; 125:915-23. [PMID: 25519749 DOI: 10.1182/blood-2014-07-590315] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The Therapeutic Intensification in De Novo Leukaemia (TIDEL)-II study enrolled 210 patients with chronic phase chronic myeloid leukemia (CML) in two equal, sequential cohorts. All started treatment with imatinib 600 mg/day. Imatinib plasma trough level was performed at day 22 and if <1000 ng/mL, imatinib 800 mg/day was given. Patients were then assessed against molecular targets: BCR-ABL1 ≤10%, ≤1%, and ≤0.1% at 3, 6, and 12 months, respectively. Cohort 1 patients failing any target escalated to imatinib 800 mg/day, and subsequently switched to nilotinib 400 mg twice daily for failing the same target 3 months later. Cohort 2 patients failing any target switched to nilotinib directly, as did patients with intolerance or loss of response in either cohort. At 2 years, 55% of patients remained on imatinib, and 30% on nilotinib. Only 12% were >10% BCR-ABL1 at 3 months. Confirmed major molecular response was achieved in 64% at 12 months and 73% at 24 months. MR4.5 (BCR-ABL1 ≤0.0032%) at 24 months was 34%. Overall survival was 96% and transformation-free survival was 95% at 3 years. This trial supports the feasibility and efficacy of an imatinib-based approach with selective, early switching to nilotinib. This trial was registered at www.anzctr.org.au as #12607000325404.
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Rea D, Mirault T, Raffoux E, Boissel N, Andreoli AL, Rousselot P, Dombret H, Messas E. Usefulness of the 2012 European CVD risk assessment model to identify patients at high risk of cardiovascular events during nilotinib therapy in chronic myeloid leukemia. Leukemia 2014; 29:1206-9. [DOI: 10.1038/leu.2014.342] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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153
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Clinical lessons to be learned from patients developing chronic myeloid leukemia while on immunosuppressive therapy after solid organ transplantation: yet another case after orthotopic heart transplantation. Case Rep Hematol 2014; 2014:890438. [PMID: 25478254 PMCID: PMC4248424 DOI: 10.1155/2014/890438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 10/23/2014] [Accepted: 10/24/2014] [Indexed: 12/25/2022] Open
Abstract
Chronic myeloid leukemia developing after transplantation of solid organs and concomitant immunosuppression is a rare but still significant clinical phenomenon. We here describe an additional case of a 62-year-old male patient developing CML after orthotopic heart transplantation and medication with cyclosporine A, mofetil-mycophenolate, and steroids. Initial antileukemic therapy was imatinib at a standard dose and within 15 months of therapy a complete cytogenetic response was noted. In this report we discuss the clinical implications of these rare but biologically important cases.
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154
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Radonjic-Hoesli S, Valent P, Klion AD, Wechsler ME, Simon HU. Novel targeted therapies for eosinophil-associated diseases and allergy. Annu Rev Pharmacol Toxicol 2014; 55:633-56. [PMID: 25340931 DOI: 10.1146/annurev-pharmtox-010814-124407] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Eosinophil-associated diseases often present with life-threatening manifestations and/or chronic organ damage. Currently available therapeutic options are limited to a few drugs that often have to be prescribed on a lifelong basis to keep eosinophil counts under control. In the past 10 years, treatment options and outcomes in patients with clonal eosinophilic and other eosinophilic disorders have improved substantially. Several new targeted therapies have emerged, addressing different aspects of eosinophil expansion and inflammation. In this review, we discuss available and currently tested agents as well as new strategies and drug targets relevant to both primary and secondary eosinophilic diseases, including allergic disorders.
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155
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Breccia M, Molica M, Zacheo I, Serrao A, Alimena G. Application of systematic coronary risk evaluation chart to identify chronic myeloid leukemia patients at risk of cardiovascular diseases during nilotinib treatment. Ann Hematol 2014; 94:393-7. [PMID: 25304102 DOI: 10.1007/s00277-014-2231-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/05/2014] [Indexed: 10/24/2022]
Abstract
Nilotinib is currently approved for the treatment of chronic myeloid leukemia (CML) in chronic (CP) and accelerated phase (AP) after failure of imatinib and in newly diagnosed patients. Atherosclerotic events were retrospectively reported in patients with baseline cardiovascular risk factors during nilotinib treatment. We estimated the risk of developing atherosclerotic events in patients treated with second or first-line nilotinib, with a median follow-up of 48 months, by retrospectively applying the SCORE chart proposed by the European Society of Cardiology (ESC) and evaluating risk factors at baseline (diabetes, obesity, smoking, and hypertension). Overall, we enrolled in the study 82 CP patients treated frontline (42 CP patients at the dose of 600 mg BID) or after failure of other tyrosine kinase inhibitors (40 CP patients treated with 400 mg BID). The SCORE chart is based on the stratification of sex (male vs female), age (from 40 to 65 years), smoker vs non-smoker, systolic pressure (from 120 to 180 mm Hg), and cholesterol (measured in mmol/l, from 150 to 300 mg/dl). For statistical purposes, we considered patients subdivided in low, moderate, high (with a score >5), and very high risk. There were 48 males and 34 females, median age 51 years (range 22-84). According to WHO classification, 42 patients were classified as normal weight (BMI <25), 26 patients were overweight (BMI 26 ≤ 30), and 14 were obese (BMI >30). Retrospective classification according to the SCORE chart revealed that 27 patients (33 %) were in the low-risk category, 30 patients (36 %) in the moderate risk category, and 24 patients (29 %) in the high risk. As regards risk factors, we revealed that 17 patients (20.7 %) had a concomitant type II controlled diabetes (without organ damage), 23 patients (28 %) were smokers, 29 patients (35 %) were receiving concomitant drugs for hypertension, and 15 patients (18 %) had concomitant dyslipidemia. Overall, the cumulative incidence of atherosclerotic events at 48 months was 8.5 % (95 % CI, 4.55-14.07): None of the low-risk patients according to the SCORE chart experienced atherosclerotic events compared to 10 % in the moderate risk category and 29 % in the high risk (p = 0.002). Atherosclerotic-free survival was 100, 89, and 69 % in the low, moderate, and high-risk population, respectively (p = 0.001). SCORE chart evaluation at disease baseline could be a valid tool to identify patients at high risk of atherosclerotic events during nilotinib treatment.
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Affiliation(s)
- Massimo Breccia
- Department of Cellular Biotechnologies and Hematology, Sapienza University, Via Benevento 6, 00161, Rome, Italy,
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156
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Herrmann J, Lerman A. An update on cardio-oncology. Trends Cardiovasc Med 2014; 24:285-95. [PMID: 25153017 PMCID: PMC4258878 DOI: 10.1016/j.tcm.2014.07.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 07/07/2014] [Accepted: 07/08/2014] [Indexed: 12/22/2022]
Abstract
Over the past decades, there have been great advancements in the survival outcome of patients with cancer. As a consequence, treatment regimens are being extended to patient populations that would not have qualified in the past based on comorbidities and age. Furthermore, the anti-cancer regimens, which have been and are being used, can cause considerable morbidity and even mortality. In fact, new drugs such as tyrosine kinase inhibitors have yielded unanticipated side effects in frequency and severity. The cardiovascular disease spectrum is an important element in all of these. In order to optimize the outcome of cancer patients with cardiovascular diseases existing prior to cancer treatment or developing as a consequence of it, a new discipline called "cardio-oncology" has evolved over the past few years. Herein, we review the latest developments in this field including cardiotoxicities, vascular toxicities, and arrhythmias. This field is taking on more shape as cardiologists, oncologists, and hematologists are forming alliances, programs, and clinics, supported by the development of expert consensus statements on best management approaches and care of the cancer patient with cardiovascular diseases.
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Affiliation(s)
- Joerg Herrmann
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
| | - Amir Lerman
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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157
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Rapid clinical improvement of peripheral artery occlusive disease symptoms after nilotinib discontinuation despite persisting vascular occlusion. Blood Cancer J 2014; 4:e247. [PMID: 25238138 PMCID: PMC4183775 DOI: 10.1038/bcj.2014.66] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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158
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Katgı A, Sevindik ÖG, Gökbulut AA, Özsan GH, Yüksel F, Solmaz ŞM, Alacacıoğlu İ, Özcan MA, Demirkan F, Baran Y, Pişkin Ö. Nilotinib Does Not Alter the Secretory Functions of Carotid Artery Endothelial Cells in a Prothrombotic or Antithrombotic Fashion. Clin Appl Thromb Hemost 2014; 21:678-83. [DOI: 10.1177/1076029614550817] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: There have been concerns about the possible prothrombotic effects of nilotinib, especially in patients having cardiovascular risk factors. The potential mechanism behind the increased risk of thromboembolic events is still not clear. Objectives: In this study, we aimed to evaluate possible harmful effects of nilotinib on endothelial cells. To this aim, we examined proliferative capacity and secretory functions of healthy human carotid artery endothelial cells (HCtAECs) in response to nilotinib. Methods: 3-(4,5-Dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide (MTT) cell proliferation method was used to determine antiproliferative effects of nilotinib on HCtAECs. The HCtAECs were incubated with 5, 10, and 100 nmol/L doses of nilotinib for 72 hours. Then, in order to assess the endothelial function, levels of nitric oxide (NO), von Willebrand factor (vWF), tissue plasminogen activator, plasminogen activator inhibitor 1 (PAI-1), and endothelin 1 (ET-1) were evaluated using enzyme-linked immunosorbent assay from tissue culture supernatants. Results: There were slight but statistically significant decreases in cell proliferation in response to nilotinib. Nilotinib increased the secretion of t-PA, PAI-1, and vWF in a dose-dependent manner when compared with the untreated control group. The ET-1 secretion was lower in 5 nmol/L and higher in 10 and 100 nmol/L nilotinib-treated cells as compared to untreated cells. Regarding NO secretion, lower levels were observed in 5 and 10 nmol/L, and higher levels were detected in 100 nmol/L nilotinib-treated cells as compared to untreated control group cells. Conclusion: Considering the results obtained in our study, nilotinib does not affect the functions of endothelial cells either in a prothrombotic or an antithrombotic fashion, despite a dose-dependent decline in cell viability.
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Affiliation(s)
- Abdullah Katgı
- Department of Hematology, Dokuz Eylul University, Izmir, Turkey
| | | | - Aysun Adan Gökbulut
- Department of Molecular Biology and Genetics, Izmir Institute of Technology, Izmir, Turkey
| | | | - Faize Yüksel
- Department of Hematology, Dokuz Eylul University, Izmir, Turkey
| | | | | | | | - Fatih Demirkan
- Department of Hematology, Dokuz Eylul University, Izmir, Turkey
| | - Yusuf Baran
- Department of Molecular Biology and Genetics, Izmir Institute of Technology, Izmir, Turkey
| | - Özden Pişkin
- Department of Hematology, Dokuz Eylul University, Izmir, Turkey
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159
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Raanani P, Granot G, Ben-Bassat I. Is cure of chronic myeloid leukemia in the third millennium a down to earth target (ed) or a castle in the air? Cancer Lett 2014; 352:21-7. [DOI: 10.1016/j.canlet.2014.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 01/06/2014] [Accepted: 01/13/2014] [Indexed: 01/14/2023]
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160
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Mirault T, Rea D, Azarine A, Messas E. Rapid onset of peripheral artery disease in a chronic myeloid leukemia patient without prior arterial disorder: direct relationship with nilotinib exposure and clinical outcome. Eur J Haematol 2014; 94:363-7. [PMID: 24797802 DOI: 10.1111/ejh.12367] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2014] [Indexed: 12/31/2022]
Abstract
The second-generation tyrosine kinase inhibitor (TKI) of the BCR-ABL1 oncoprotein nilotinib used in patients with chronic myeloid leukemia is suspected to increase the risk of arterial occlusion, especially in patients with pre-existing cardiovascular risk factors or established cardiovascular diseases. Here, we describe a case of unexpected and rapid onset of symptomatic peripheral artery disease (PAD) associated with silent stenosis of digestive and renal arteries in a nilotinib-treated patient devoid of significant cardiovascular diseases (CVD) risk factor, prior atherosclerotic disease, or other cause of arterial damage. This is the first report to establish a direct relationship between nilotinib exposure and PAD and to reveal that arterial damage is irreversible despite rapid drug withdrawal. However, functional outcome was favorable upon rapid TKI replacement, specific cardiovascular disease management, and development of collateral arterial network.
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Affiliation(s)
- Tristan Mirault
- Médecine Vasculaire, Hôpital Européen Georges-Pompidou, AP-HP, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Paris, France; INSERM U970, PARCC, Paris, France
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161
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Delord M, Rousselot P, Cayuela JM, Sigaux F, Guilhot J, Preudhomme C, Guilhot F, Loiseau P, Raffoux E, Geromin D, Génin E, Calvo F, Bruzzoni-Giovanelli H. High imatinib dose overcomes insufficient response associated with ABCG2 haplotype in chronic myelogenous leukemia patients. Oncotarget 2014; 4:1582-91. [PMID: 24123600 PMCID: PMC3858547 DOI: 10.18632/oncotarget.1050] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pharmacogenetic studies in chronic myelogenous leukemia (CML) typically use a candidate gene approach. In an alternative strategy, we analyzed the impact of single nucleotide polymorphisms (SNPs) in drug transporter genes on the molecular response to imatinib, using a DNA chip containing 857 SNPs covering 94 drug transporter genes. Two cohorts of CML patients treated with imatinib were evaluated: an exploratory cohort including 105 patients treated at 400 mg/d and a validation cohort including patients sampled from the 400 mg/d and 600 mg/d arms of the prospective SPIRIT trial (n=239). Twelve SNPs discriminating patients according to cumulative incidence of major molecular response (CI-MMR) were identified within the exploratory cohort. Three of them, all located within the ABCG2 gene, were validated in patients included in the 400 mg/d arm of the SPIRIT trial. We identified an ABCG2 haplotype (define as G-G, rs12505410 and rs2725252) as associated with significantly higher CI-MMR in patients treated at 400 mg/d. Interestingly, we found that patients carrying this ABCG2 "favorable" haplotype in the 400 mg arm reached similar CI-MMR rates that patients randomized in the imatinib 600 mg/d arm. Our results suggest that response to imatinib may be influenced by constitutive haplotypes in drug transporter genes. Lower response rates associated with "non- favorable" ABCG2 haplotypes may be overcome by increasing the imatinib daily dose up to 600 mg/d.
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Affiliation(s)
- Marc Delord
- Plateforme de Bioinformatique et Biostatistique, Institut Universitaire d'Hématologie, Université Paris Diderot, Sorbonne Paris Cité
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162
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Second-Line Therapy for Patients With Chronic Myeloid Leukemia Resistant to First-Line Imatinib. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:186-96. [DOI: 10.1016/j.clml.2013.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/23/2013] [Accepted: 11/05/2013] [Indexed: 11/22/2022]
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163
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Abstract
Targeted therapy is the buzz word these days. A decade back the emergence of tyrosine kinase inhibitor Imatinib on the horizon, as the targeted therapy, had captured the imagination of everyone in the field of cancer. It is encouraging to see a large number of patients getting relief from deadly CML disease and leading a good quality of life with the help of this drug. However, sky is not the limit and now we have second and third generation tyrosine kinase inhibitors. I still remember the sagacious smile on the face of late Dr. John Goldman, when I asked him about his preferred choice and he replied and I quote “this is going to be the debate of the decade.” Here I take the opportunity to contribute to this debate. I have scrutinized various aspects of the three TKIs, now recommended, for the treatment of CML. I’m still convinced it is too early to shift our practice completely towards 2G TKI as more time is required to make a clear recommendation.
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Affiliation(s)
- Shweta Bansal
- Department of Pediatric Oncology, Asian Institute of Oncology, K J Somaiya Hospital, Sion, Mumbai, Maharashtra, India
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164
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Statins inhibit ABCB1 and ABCG2 drug transporter activity in chronic myeloid leukemia cells and potentiate antileukemic effects of imatinib. Exp Hematol 2014; 42:439-47. [PMID: 24667683 DOI: 10.1016/j.exphem.2014.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 02/13/2014] [Accepted: 02/24/2014] [Indexed: 01/07/2023]
Abstract
Despite undisputed success of tyrosine kinase inhibitors in the therapy of chronic myeloid leukemia (CML), development of drug resistance and inability to cure the disease challenge clinicians and researchers. Additionally, recent reports regarding cardiovascular toxicities of second and third generation tyrosine kinase inhibitors prove that there is still a place for novel therapeutic combinations in CML. We have previously shown that statins are able to modulate activity of chemotherapeutics or antibodies used in oncology. Therefore, we decided to verify that statins are able to potentiate antileukemic activity of imatinib, still a frontline treatment of CML. Lovastatin, a cholesterol lowering drug, synergistically potentiates antileukemic activity of imatinib in cell lines and in primary CD34+ CML cells from patients in different phases of the disease, including patients resistant to imatinib with no detectable mutations. This effect is related to increased intracellular concentration of imatinib in CD34+ CML cells and cell lines measured using uptake of (14)C-labeled imatinib. Lovastatin does not influence influx but significantly inhibits efflux of imatinib mediated by ATP-binding cassette (ABC) transporters: ABCB1 and ABCG2. The addition of cholesterol completely reverses these effects. Statins do not affect expression of ABCB1 and ABCG2 genes. The effects are drug-class specific, as observed with other statins. Our results suggest that statins may offer a valuable addition to imatinib in a select group of CML patients.
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165
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Rea D, Mirault T, Cluzeau T, Gautier JF, Guilhot F, Dombret H, Messas E. Early onset hypercholesterolemia induced by the 2nd-generation tyrosine kinase inhibitor nilotinib in patients with chronic phase-chronic myeloid leukemia. Haematologica 2014; 99:1197-203. [PMID: 24658819 DOI: 10.3324/haematol.2014.104075] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite a well-recognized clinical benefit of the 2(nd)-generation tyrosine kinase inhibitor nilotinib in patients with imatinib-resistant/-intolerant or newly diagnosed chronic myeloid leukemia, recent evidence suggests that nilotinib has a propensity to increase the risk of occlusive arterial events, especially in patients with pre-existing cardiovascular risk factors. Given the key role of lipids in cardiovascular diseases, we studied the plasma lipid profile and global cardiovascular risk prior to and during nilotinib therapy in a series of 27 patients in the setting of a prospective single center study. Data from a minimum 1-year follow up showed that nilotinib significantly increased total, low- and high-density lipoprotein cholesterol within three months. Consequently, the proportion of patients with non-optimal low-density lipoprotein cholesterol increased from 48.1% to 88.9% by 12 months, leading to cholesterol-lowering drug intervention in 22.2% of patients. The proportion of patients with low levels of high-density lipoprotein cholesterol decreased from 40.7% to 7.4% by 12 months. In contrast, a significant decrease in triglycerides was observed. Global cardiovascular risk worsened in 11.1% of patients due to diabetes or occlusive arterial events. Whether hypercholesterolemia was the main driver of occlusive arterial events was uncertain: a longer follow up is necessary to ask whether nilotinib-induced hypercholesterolemia increases long-term risk of atherosclerotic diseases. Nevertheless, given key atherogenic properties of low-density lipoprotein cholesterol, we conclude that when prescribing nilotinib, commitment to detect lipid disorders at baseline and during follow up is mandatory given their frequency, requirement for changes in lifestyle or drug intervention, and potential for long-term cardiovascular complications.
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Affiliation(s)
- Delphine Rea
- Service d'Hématologie Adulte, Hôpital Saint-Louis, AP-HP, Paris
| | - Tristan Mirault
- Service de Médecine Vasculaire and INSERM UMR970, PARCC, Hôpital Européen Georges Pompidou, AP-HP, Paris
| | - Thomas Cluzeau
- Service d'Hématologie Adulte, Hôpital Saint-Louis, AP-HP, Paris
| | | | - François Guilhot
- INSERM Centre d'Investigation Clinique 1402, CHU de Poitiers, France
| | - Hervé Dombret
- Service d'Hématologie Adulte, Hôpital Saint-Louis, AP-HP, Paris
| | - Emmanuel Messas
- Service de Médecine Vasculaire and INSERM UMR970, PARCC, Hôpital Européen Georges Pompidou, AP-HP, Paris
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166
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Vergès B, Walter T, Cariou B. Endocrine side effects of anti-cancer drugs: effects of anti-cancer targeted therapies on lipid and glucose metabolism. Eur J Endocrinol 2014; 170:R43-55. [PMID: 24154684 DOI: 10.1530/eje-13-0586] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
During the past years, targeted therapies for cancer have been developed using drugs that have significant metabolic consequences. Among them, the mammalian target of rapamycin (mTOR) inhibitors and, to a much lesser extent, the tyrosine kinase inhibitors (TKIs) are involved. mTOR plays a key role in the regulation of cell growth as well as lipid and glucose metabolism. Treatment with mTOR inhibitors is associated with a significant increase in plasma triglycerides and LDL cholesterol. mTOR inhibitors seem to increase plasma triglycerides by reducing the activity of the lipoprotein lipase which is in charge of the catabolism of triglyceride-rich lipoproteins. The increase in LDL cholesterol observed with mTOR inhibitors seems to be due to a decrease in LDL catabolism secondary to a reduction of LDL receptor expression. In addition, treatment with mTOR inhibitors is associated with a high incidence of hyperglycemia, ranging from 13 to 50% in the clinical trials. The mechanisms responsible for hyperglycemia with new onset diabetes are not clear, but are likely due to the combination of impaired insulin secretion and insulin resistance. TKIs do not induce hyperlipidemia but alter glucose homeostasis. Treatment with TKIs may be associated either with hyperglycemia or hypoglycemia. The molecular mechanism by which TKIs control glucose homeostasis remains unknown. Owing to the metabolic consequences of these agents used as targeted anti-cancer therapies, a specific and personalized follow-up of blood glucose and lipids is recommended when using mTOR inhibitors and of blood glucose when using TKIs.
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Affiliation(s)
- Bruno Vergès
- Service Endocrinologie, Diabétologie et Maladies Métaboliques, INSERM CRI 866, Hôpital du Bocage, CHU Dijon, Université de Bourgogne, 21000 Dijon, France
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167
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Abstract
Targeted therapy of Philadelphia chromosome-positive chronic myeloid leukemia (CML) using the tyrosine kinase inhibitor imatinib mesylate has been one of the most striking achievements in modern cancer medicine. However, while imatinib can establish long-term remission in many cases, resistance to or intolerance of imatinib is eventually experienced by a substantial number of patients. Subsequent advances have led to the development of novel tyrosine kinase inhibitors (TKIs). One such inhibitor, nilotinib, was rationally designed to increase its affinity and specificity for the oncogenic tyrosine kinase Bcr-Abl compared with imatinib and has been shown to be effective after imatinib failure. Recently, nilotinib has been shown to be more effective when used as first-line therapy of chronic phase CML.
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Affiliation(s)
- Benjamin N Ostendorf
- Campus Virchow-Klinikum, Medical Department, Division of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany,
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168
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Mayer K, Gielen GH, Willinek W, Müller MC, Wolf D. Fatal progressive cerebral ischemia in CML under third-line treatment with ponatinib. Leukemia 2013; 28:976-7. [PMID: 24170029 DOI: 10.1038/leu.2013.320] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- K Mayer
- Medical Clinic III for Oncology, Haematology and Rheumatology, University Hospital Bonn (UKB), Bonn, Germany
| | - G H Gielen
- Institute of Neuropathology, University Hospital Bonn (UKB), Bonn, Germany
| | - W Willinek
- Department of Radiology, University Hospital Bonn (UKB), Bonn, Germany
| | - M C Müller
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany
| | - D Wolf
- Medical Clinic III for Oncology, Haematology and Rheumatology, University Hospital Bonn (UKB), Bonn, Germany
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169
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Gugliotta G, Castagnetti F, Fogli M, Cavo M, Baccarani M, Rosti G. Impact of comorbidities on the treatment of chronic myeloid leukemia with tyrosine-kinase inhibitors. Expert Rev Hematol 2013; 6:563-74. [PMID: 24083631 DOI: 10.1586/17474086.2013.837279] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The median age at diagnosis of chronic myeloid leukemia (CML) is between 60 and 65 years in most epidemiologic registries. Rather than age per se, a comprehensive evaluation of comorbidities may describe more properly the general clinical status of a patient. Tyrosine-kinase inhibitors (TKIs) have a different tolerability profile, and some adverse events (AEs) are peculiar of each drug, in particular, in presence of predisposing factors (comorbidities, concomitant medications). This article will review the impact of comorbidities in the safety and outcome of CML patients treated with TKIs. We will explore how the comorbidity status may be considered, together with CML-related factors, in the selection of the TKI in order to optimize treatment.
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Affiliation(s)
- Gabriele Gugliotta
- Department of Experimental, Diagnostic and Specialty Medicine, S.Orsola-Malpighi Hospital, University of Bologna, Institute of Hematology "L. e A. Seragnòli", Bologna, Italy
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170
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Cerrano M, Crisà E, Pregno P, Aguzzi C, Riccomagno P, Boccadoro M, Ferrero D. Excellent therapeutic results achieved in chronic myeloid leukemia patients with front-line imatinib and early treatment modifications in suboptimal responders: a retrospective study on 91 unselected patients. Am J Hematol 2013; 88:838-42. [PMID: 23757199 DOI: 10.1002/ajh.23501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 05/27/2013] [Accepted: 05/28/2013] [Indexed: 12/15/2022]
Abstract
Second generation tyrosine kinase-inhibitors (TKI) have been claimed to represent now the first-choice therapy for chronic myeloid leukemia (CML). Indeed, they generally induce faster and deeper molecular responses compared to imatinib that, however, is equally effective in at least 50% of patients. Moreover, some recent reports have questioned the long term safety of dasatinib and nilotinib. Therefore, upfront imatinib with early shift to second generation TKI for patients with slow/incomplete response might be as effective as front-line second generation TKI, with a possibly better safety profile. We retrospectively evaluated 91 chronic phase CML patients (median follow-up 57 months, median age 61 years), treated front-line with standard-dose imatinib and early therapy modifications (at 3-12 months) in case of unsatisfactory response or intolerance. Thirty-three patients (24 with unsatisfactory response, 9 intolerant) changed therapy, either by increasing imatinib dose (11/91) or by switching to second generation TKI (22 directly, 4 after high-dose imatinib). Globally, our strategy led to complete cytogenetic response (CCyR) in 98% of the patients, major molecular response (MMR) in 88% and molecular response 4 logs (MR(4.0) ) in 62%. Three patients in CCyR (3%), 2 of them in MMR too, suddenly progressed to blastic phase. At the last follow-up nine patients had died, seven of CML-unrelated causes and two only of CML progression. These results suggest that our strategy could be as effective as front line second generation TKI, with most of patients still receiving imatinib, a drug of better known long-term side effects and lower cost.
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Affiliation(s)
- Marco Cerrano
- Hematology Division; Università degli Studi di Torino; Turin Italy
| | - Elena Crisà
- Hematology Division; Università degli Studi di Torino; Turin Italy
| | - Patrizia Pregno
- Hematology Division; Azienda Ospedaliera Città della Salute e della Scienza; Turin Italy
| | - Chiara Aguzzi
- Hematology Division; Università degli Studi di Torino; Turin Italy
| | - Paola Riccomagno
- Hematology Division; Azienda Ospedaliera Città della Salute e della Scienza; Turin Italy
| | - Mario Boccadoro
- Hematology Division; Università degli Studi di Torino; Turin Italy
| | - Dario Ferrero
- Hematology Division; Università degli Studi di Torino; Turin Italy
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171
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Bhattacharya PK, Bhattacharya U, Bhattacharya R, Bhattacharya R, Bhattacharya S, Bhattacharya R, Mukherjee D, Mukherjee O, Mukherjee D, Barman DR, Das S, Dey A, Biswas RR, Sarkar S. Next generation therapy in chronic myeloid leukemia. Indian J Hematol Blood Transfus 2013; 28:189-90. [PMID: 23997460 DOI: 10.1007/s12288-011-0139-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 12/08/2011] [Indexed: 11/25/2022] Open
Affiliation(s)
- Pranab Kumar Bhattacharya
- Department of Pathology & Hematology, Calcutta School of Tropical Medicine, C.R. Avenue, Kolkata, 73 WB India ; Calcutta School of Tropical Medicine, 108 CR Avenue, Kolkata, 73 India
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172
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Conti E, Romiti A, Musumeci MB, Passerini J, Zezza L, Mastromarino V, D'Antonio C, Marchetti P, Paneni F, Autore C, Volpe M. Arterial thrombotic events and acute coronary syndromes with cancer drugs: Are growth factors the missed link? Int J Cardiol 2013; 167:2421-9. [DOI: 10.1016/j.ijcard.2013.01.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/18/2013] [Indexed: 12/21/2022]
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173
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Baccarani M, Deininger MW, Rosti G, Hochhaus A, Soverini S, Apperley JF, Cervantes F, Clark RE, Cortes JE, Guilhot F, Hjorth-Hansen H, Hughes TP, Kantarjian HM, Kim DW, Larson RA, Lipton JH, Mahon FX, Martinelli G, Mayer J, Müller MC, Niederwieser D, Pane F, Radich JP, Rousselot P, Saglio G, Saußele S, Schiffer C, Silver R, Simonsson B, Steegmann JL, Goldman JM, Hehlmann R. European LeukemiaNet recommendations for the management of chronic myeloid leukemia: 2013. Blood 2013; 122:872-84. [PMID: 23803709 PMCID: PMC4915804 DOI: 10.1182/blood-2013-05-501569] [Citation(s) in RCA: 1408] [Impact Index Per Article: 128.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/10/2013] [Indexed: 02/07/2023] Open
Abstract
Advances in chronic myeloid leukemia treatment, particularly regarding tyrosine kinase inhibitors, mandate regular updating of concepts and management. A European LeukemiaNet expert panel reviewed prior and new studies to update recommendations made in 2009. We recommend as initial treatment imatinib, nilotinib, or dasatinib. Response is assessed with standardized real quantitative polymerase chain reaction and/or cytogenetics at 3, 6, and 12 months. BCR-ABL1 transcript levels ≤10% at 3 months, <1% at 6 months, and ≤0.1% from 12 months onward define optimal response, whereas >10% at 6 months and >1% from 12 months onward define failure, mandating a change in treatment. Similarly, partial cytogenetic response (PCyR) at 3 months and complete cytogenetic response (CCyR) from 6 months onward define optimal response, whereas no CyR (Philadelphia chromosome-positive [Ph+] >95%) at 3 months, less than PCyR at 6 months, and less than CCyR from 12 months onward define failure. Between optimal and failure, there is an intermediate warning zone requiring more frequent monitoring. Similar definitions are provided for response to second-line therapy. Specific recommendations are made for patients in the accelerated and blastic phases, and for allogeneic stem cell transplantation. Optimal responders should continue therapy indefinitely, with careful surveillance, or they can be enrolled in controlled studies of treatment discontinuation once a deeper molecular response is achieved.
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Affiliation(s)
- Michele Baccarani
- Department of Hematology L. and A. Seràgnoli, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna, Italy.
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174
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Abstract
Imatinib has been the preferred initial therapy for newly diagnosed chronic myeloid leukemia (CML) patients for the last 10 years. Today, other tyrosine kinase inhibitors (TKIs) are licensed for first-line use. In this paper we analyze the pros and cons of the various alternatives to imatinib and try to give some advice on the management of the newly diagnosed patient.
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Affiliation(s)
- David Marin
- Department of Haematology, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK.
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175
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Abstract
PURPOSE OF REVIEW In this review, we analyze some of the topical issues in the clinical management of chronic myeloid leukaemia (CML). RECENT FINDINGS In recent years, the management of CML patients has increased in complexity as molecular monitoring has brought to the clinical scene new therapeutic targets and the second-generation tyrosine kinase inhibitors have been licensed for first-line use. SUMMARY In this article, we will try to answer some of the questions that a practising physician may face in clinical practice, such as: What should be the aim of therapy? What is the best front-line therapy? Which patients should receive an allogeneic stem cell transplant?
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176
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Abl kinases are required for vascular function, Tie2 expression, and angiopoietin-1-mediated survival. Proc Natl Acad Sci U S A 2013; 110:12432-7. [PMID: 23840065 DOI: 10.1073/pnas.1304188110] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Endothelial dysfunction is associated with diverse cardiovascular pathologies. Here, we show a previously unappreciated role for the Abelson (Abl) family kinases (Abl and Arg) in endothelial function and the regulation of angiogenic factor pathways important for vascular homeostasis. Endothelial Abl deletion in Arg-null mice led to late-stage embryonic and perinatal lethality, with mutant mice displaying focal loss of vasculature and tissue necrosis. Loss of Abl kinases led to increased endothelial cell apoptosis both in vitro and in vivo, contributing to vascular dysfunction, infarction, and tissue damage. Mechanistically, we identify a unique dual role for Abl kinases in the regulation of angiopoietin/Tie2 protein kinase signaling. Endothelial Abl kinases modulate Tie2 expression and angiopoietin-1-mediated endothelial cell survival. These findings reveal a critical requirement for the Abl kinases in vascular development and function, which may have important implications for the clinical use of Abl kinase inhibitors.
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177
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Dy GK, Adjei AA. Understanding, recognizing, and managing toxicities of targeted anticancer therapies. CA Cancer J Clin 2013; 63:249-79. [PMID: 23716430 DOI: 10.3322/caac.21184] [Citation(s) in RCA: 227] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 02/21/2013] [Accepted: 02/25/2013] [Indexed: 12/11/2022] Open
Abstract
Answer questions and earn CME/CNE Advances in genomics and molecular biology have identified aberrant proteins in cancer cells that are attractive targets for cancer therapy. Because these proteins are overexpressed or dysregulated in cancer cells compared with normal cells, it was assumed that their inhibitors will be narrowly targeted and relatively nontoxic. However, this hope has not been achieved. Current targeted agents exhibit the same frequency and severity of toxicities as traditional cytotoxic agents, with the main difference being the nature of the toxic effects. Thus, the classical chemotherapy toxicities of alopecia, myelosuppression, mucositis, nausea, and vomiting have been generally replaced by vascular, dermatologic, endocrine, coagulation, immunologic, ocular, and pulmonary toxicities. These toxicities need to be recognized, prevented, and optimally managed.
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Affiliation(s)
- Grace K Dy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
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178
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Coon EA, Zalewski NL, Hoffman EM, Tefferi A, Flemming KD. Nilotinib treatment-associated cerebrovascular disease and stroke. Am J Hematol 2013; 88:534-5. [PMID: 23526495 DOI: 10.1002/ajh.23442] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 03/15/2013] [Accepted: 03/19/2013] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Ayalew Tefferi
- Department of Hematology; Mayo Clinic; Rochester; Minnesota
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179
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Racil Z, Razga F, Drapalova J, Buresova L, Zackova D, Palackova M, Semerad L, Malaskova L, Haluzik M, Mayer J. Mechanism of impaired glucose metabolism during nilotinib therapy in patients with chronic myelogenous leukemia. Haematologica 2013; 98:e124-6. [PMID: 23716549 DOI: 10.3324/haematol.2013.086355] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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180
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Tefferi A. Nilotinib treatment-associated accelerated atherosclerosis: when is the risk justified? Leukemia 2013; 27:1939-40. [PMID: 23604230 PMCID: PMC3768111 DOI: 10.1038/leu.2013.112] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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181
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Irvine E, Williams C. Treatment-, Patient-, and Disease-Related Factors and the Emergence of Adverse Events with Tyrosine Kinase Inhibitors for the Treatment of Chronic Myeloid Leukemia. Pharmacotherapy 2013; 33:868-81. [DOI: 10.1002/phar.1266] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Elizabeth Irvine
- Department of Pharmacy; University of Kansas Hospital; Kansas City; Kansas
| | - Casey Williams
- Sanford Research/USD; Edith Sanford Breast Cancer Initiative; Sioux Falls; South Dakota
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182
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Levato L, Cantaffa R, Kropp MG, Magro D, Piro E, Molica S. Progressive peripheral arterial occlusive disease and other vascular events during nilotinib therapy in chronic myeloid leukemia: a single institution study. Eur J Haematol 2013; 90:531-2. [PMID: 23506097 DOI: 10.1111/ejh.12096] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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183
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Abstract
Cardiovascular toxicity caused by cancer therapy is a challenging area which needs thorough evaluation and research. Numerous studies, meta-analyses and reviews have been published in the past discussing cardiotoxicity caused by chemotherapeutic agents. A brief review of the on-target and off-target cardiotoxicities caused by chemotherapeutic agents is presented here. Cardiotoxicities are broadly outlined in terms of left ventricular dysfunction, hypertension and thromboembolic events. The mechanisms leading to the cardiotoxicity profiles of various chemotherapeutic agents are discussed. The management of various cardiotoxicities of chemotherapeutic agents is also discussed.
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Affiliation(s)
- Saurabh Aggarwal
- Department of Medicine, Chicago Medical School/Rosalind Franklin University, 3333, Green Bay Road, North Chicago, IL 60064, USA
| | - Jasmine Kamboj
- Department of Medicine, Chicago Medical School/Rosalind Franklin University, North Chicago, IL, USA
| | - Rohit Arora
- Department of Medicine, Chicago Medical School/Rosalind Franklin University, North Chicago, IL, USA
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184
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Breccia M, Alimena G. Occurrence and current management of side effects in chronic myeloid leukemia patients treated frontline with tyrosine kinase inhibitors. Leuk Res 2013; 37:713-20. [PMID: 23473918 DOI: 10.1016/j.leukres.2013.01.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 01/28/2013] [Accepted: 01/29/2013] [Indexed: 11/15/2022]
Abstract
Tyrosine kinase inhibitors (TKIs) represent the gold standard therapy of chronic myeloid leukemia and, after being used in imatinib resistant patients, dasatinib and nilotinib are now also used in frontline. In this article, we review data about occurrence of side effects in several trials testing imatinib or second-generation tyrosine kinase inhibitors first line. Literature data about high-dose imatinib used front-line as single treatment or with different combinations is also examined. A literature search for relevant studies was undertaken mainly in PubMed. This review is aimed to summarize the safety of different treatments and to discuss the current management of most common side effects. Literature evidence supports the fact that side effects associated to TKIs seem to differ between agents, but most of side effects reported occur early within the treatment course. Second generation frontline TKIs reduce the incidence of most of side effects reported with imatinib and peculiar events observed are typically manageable through drug dose reduction or treatment interruption.
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Affiliation(s)
- Massimo Breccia
- Department of Cellular Biotechnology and Hematology, Sapienza University, Rome, Italy.
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185
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Giles FJ, Mauro MJ, Hong F, Ortmann CE, McNeill C, Woodman RC, Hochhaus A, le Coutre PD, Saglio G. Rates of peripheral arterial occlusive disease in patients with chronic myeloid leukemia in the chronic phase treated with imatinib, nilotinib, or non-tyrosine kinase therapy: a retrospective cohort analysis. Leukemia 2013; 27:1310-5. [PMID: 23459450 DOI: 10.1038/leu.2013.69] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Peripheral arterial occlusive disease (PAOD) occurs in patients with chronic phase chronic myeloid leukemia (CML-CP) treated with tyrosine kinase inhibitors (TKIs). The risk of developing PAOD on TKI therapy is unknown and causality has not been established. Patients with CML-CP from three randomized phase III studies (IRIS, TOPS and ENESTnd) were divided into three cohorts: no TKI (cohort 1; n=533), nilotinib (cohort 2; n=556) and imatinib (cohort 3; n=1301). Patients with atherosclerotic risk factors were not excluded. Data were queried for terms indicative of PAOD. Overall, 3, 7 and 2 patients in cohorts 1, 2 and 3, respectively, had PAOD; 11/12 patients had baseline PAOD risk factors. Compared with that of cohort 1, exposure-adjusted risks of PAOD for cohorts 2 and 3 were 0.9 (95% CI, 0.2-3.3) and 0.1 (95% CI, 0.0-0.5), respectively. Multivariate logistic regression revealed that nilotinib had no impact on PAOD rates compared with no TKI, whereas imatinib had decreased rates of PAOD compared with no TKI. Nilotinib was associated with higher rates of PAOD versus imatinib. Baseline assessments, preferably within clinical studies, of PAOD and associated risk factors should occur when initiating TKI therapy in CML; patients should receive monitoring and treatment according to the standard of care for these comorbidities.
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Affiliation(s)
- F J Giles
- HRB Clinical Research Facility, National University of Ireland Galway and Trinity College Dublin, Dublin, Ireland.
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186
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Peripheral artery occlusive disease in chronic phase chronic myeloid leukemia patients treated with nilotinib or imatinib. Leukemia 2013; 27:1316-21. [PMID: 23459449 DOI: 10.1038/leu.2013.70] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Several retrospective studies have described the clinical manifestation of peripheral artery occlusive disease (PAOD) in patients receiving nilotinib. We thus prospectively screened for PAOD in patients with chronic phase chronic myeloid leukemia (CP CML) being treated with tyrosine kinase inhibitors (TKI), including imatinib and nilotinib. One hundred and fifty-nine consecutive patients were evaluated for clinical and biochemical risk factors for cardiovascular disease. Non-invasive assessment for PAOD included determination of the ankle-brachial index (ABI) and duplex ultrasonography. A second cohort consisted of patients with clinically manifest PAOD recruited from additional collaborating centers. Pathological ABI were significantly more frequent in patients on first-line nilotinib (7 of 27; 26%) and in patients on second-line nilotinib (10 of 28; 35.7%) as compared with patients on first-line imatinib (3 of 48; 6.3%). Clinically manifest PAOD was identified in five patients, all with current or previous nilotinib exposure only. Relative risk for PAOD determined by a pathological ABI in first-line nilotinib-treated patients as compared with first-line imatinib-treated patients was 10.3. PAOD is more frequently observed in patients receiving nilotinib as compared with imatinib. Owing to the severe nature of clinically manifest PAOD, longitudinal non-invasive monitoring and careful assessment of risk factors is warranted.
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187
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Abstract
Mast cells are increasingly being recognized as effector cells in many cardiovascular conditions. Many mast-cell-derived products such as tryptase and chymase can, through their enzymic action, have detrimental effects on blood vessel structure while mast cell-derived mediators such as cytokines and chemokines can perpetuate vascular inflammation. Mice lacking mast cells have been developed and these are providing an insight into how mast cells are involved in cardiovascular diseases and, as knowledge increase, mast cells may become a viable therapeutic target to slow progression of cardiovascular disease.
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188
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Hughes T, White D. Which TKI? An embarrassment of riches for chronic myeloid leukemia patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:168-175. [PMID: 24319178 DOI: 10.1182/asheducation-2013.1.168] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
With the approval in many countries of nilotinib and dasatinib for frontline therapy in chronic myeloid leukemia, clinicians now have to make a difficult choice. Because none of the 3 available tyrosine kinase inhibitors (TKIs) have shown a clear survival advantage, they all represent reasonable choices. However, in individual patients, the case may be stronger for a particular TKI. In the younger patient, in whom the prospect of eventually achieving treatment-free remission is likely to be of great importance, dasatinib or nilotinib may be preferred, although their advantage over imatinib in this setting remains to be proven. In patients with a higher risk of transformation (which is currently based on prognostic scoring), the more potent TKIs may be preferred because they appear to be more effective at reducing the risk of transformation to BC. However, imatinib still represents an excellent choice for many chronic myeloid leukemia patients. All of these considerations need to be made in the context of the patient's comorbidities, which may lead to one or more TKIs being ruled out of contention. Whatever first choice of TKI is made, treatment failure or intolerance must be recognized early because a prompt switch to another TKI likely provides the best chance of achieving optimal response.
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Affiliation(s)
- Timothy Hughes
- 1South Australian Health and Medical Research Institute, SA Pathology, and University of Adelaide, Adelaide, Australia
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189
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Abstract
Abstract
Imatinib has been the preferred initial therapy for newly diagnosed chronic myeloid leukemia patients for the past 10 years. Recently, other, possibly better, tyrosine kinase inhibitors have been licensed for first-line use based on the early results of 2 large, randomized clinical trials. The pros and cons of the various alternatives to imatinib are analyzed herein, and I try to answer the question of are we ready to abandon imatinib and, if yes, then what treatment should a patient diagnosed today receive.
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190
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Kristensen T, Randers E, Stentoft J. Bilateral renal artery stenosis in a patient with chronic myeloid leukemia treated with nilotinib. Leuk Res Rep 2012; 1:1-3. [PMID: 24371759 DOI: 10.1016/j.lrr.2012.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 09/09/2012] [Accepted: 09/17/2012] [Indexed: 11/24/2022] Open
Abstract
Previously authors have recently described an association between nilotinib therapy for chronic myeloid leukemia (CML) and severe peripheral artery disease, coronary artery disease and sudden death. We present a case report of a male patient with CML who received nilotinib therapy. He developed bilateral renal artery stenosis and renovascular hypertension. He had no history of hypertension, cardiovascular disease, or diabetes, and he was a nonsmoker. Together, these observations indicated that obtaining further understanding of the effects is necessary and that extreme caution is warranted when considering second-generation tyrosine kinase inhibitors for first-line therapy in CML.
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Affiliation(s)
- Tilde Kristensen
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Else Randers
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Jesper Stentoft
- Department of Hematology, University Hospital Aarhus, Aarhus, Denmark
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191
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DeAngelo DJ. Managing chronic myeloid leukemia patients intolerant to tyrosine kinase inhibitor therapy. Blood Cancer J 2012; 2:e95. [PMID: 23085780 PMCID: PMC3483619 DOI: 10.1038/bcj.2012.30] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 06/15/2012] [Indexed: 01/27/2023] Open
Abstract
The outcomes for patients with chronic myeloid leukemia have improved dramatically with the development and availability of BCR-ABL1 tyrosine kinase inhibitors (TKIs) over the past decade. TKI therapy has a superior safety profile compared with the previous standard of care, interferon-α, and most adverse events (AEs) observed with front-line and second-line TKI treatment are managed with supportive care. However, some patients are intolerant to TKI therapy and experience AEs that cannot be managed through dose reduction or symptomatic treatment. Careful management of AEs helps patients to remain adherent with treatment and increases their chances for successful outcomes. Proactive vigilance for potential AEs and treatment strategies that reduce symptom burden will help to minimize patient intolerance. This review discusses the most common AEs associated with intolerance to TKI therapy and treatment strategies to help manage patients at risk for or experiencing these events.
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Affiliation(s)
- D J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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192
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Quintás-Cardama A, Kantarjian H, Cortes J. Nilotinib-associated vascular events. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2012; 12:337-40. [PMID: 22633167 DOI: 10.1016/j.clml.2012.04.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 04/15/2012] [Accepted: 04/16/2012] [Indexed: 02/03/2023]
Abstract
Anecdotal evidence suggests that nilotinib therapy may be associated with severe peripheral artery occlusive disease (PAOD). The authors describe the experience at M.D. Anderson Cancer Center regarding vascular events associated with nilotinib therapy in patients with chronic myeloid leukemia. Overall, 5 cases of PAOD were identified among 233 patients, for an incidence of 2%. Nilotinib is a highly selective inhibitor of the inactive conformation of ABL1 kinase. An improved topologic fit to the ABL1 protein-binding surface contributes to its increased potency over imatinib. This higher selectivity in vitro translated to an improved tolerability in vivo. In fact, nilotinib therapy in the frontline phase III ENESTnd (Evaluating Nilotinib Efficacy and Safety in Clinical Trials-Newly Diagnosed Patients) study was associated with an improved toxicity profile compared with that of imatinib. Intriguingly, several cases of severe peripheral artery occlusive disease (PAOD) have been reported among patients treated with nilotinib in small series. We have identified 5 patients with chronic myeloid leukemia (CML) in whom vascular events developed that were likely related to nilotinib therapy among 233 (2%) patients treated at our institution: 1 patient had recurrent Raynaud syndrome, a second patient had recurrent cerebrovascular accidents, and 3 other patients had PAOD (2 of them with other vascular events, including coronary artery disease and pulmonary emboli, respectively). Risk factors for vascular disease were present in only 1 patient with a history of diabetes mellitus. Although the incidence of vascular events is low, this potential complication should be taken into account when selecting nilotinib for the treatment of CML.
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Affiliation(s)
- Alfonso Quintás-Cardama
- Department of Leukemia, the University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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193
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Imatinib en première ligne dans la LMC en 2012: un traitement « dépassé » ? ONCOLOGIE 2012. [DOI: 10.1007/s10269-012-2221-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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194
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Traitement par inhibiteurs de tyrosine-kinase de 2e génération chez les patients en échec de l’imatinib. ONCOLOGIE 2012. [DOI: 10.1007/s10269-012-2214-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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195
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Breccia M, Efficace F, Alimena G. Progressive arterial occlusive disease (PAOD) and pulmonary arterial hypertension (PAH) as new adverse events of second generation TKIs in CML treatment: Who's afraid of the big bad wolf? Leuk Res 2012; 36:813-4. [PMID: 22483067 DOI: 10.1016/j.leukres.2012.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 03/09/2012] [Accepted: 03/13/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Massimo Breccia
- Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy.
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196
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Steegmann JL, Cervantes F, le Coutre P, Porkka K, Saglio G. Off-target effects of BCR-ABL1 inhibitors and their potential long-term implications in patients with chronic myeloid leukemia. Leuk Lymphoma 2012; 53:2351-61. [PMID: 22616642 DOI: 10.3109/10428194.2012.695779] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In patients with chronic myeloid leukemia (CML), use of the BCR-ABL1-specific tyrosine kinase inhibitors (TKIs) imatinib, nilotinib and dasatinib has greatly improved patient survival and prolonged disease remission. More than 10 years of data from imatinib clinical studies and many years of data for nilotinib and dasatinib have demonstrated that these TKIs are well tolerated in most patients with CML. However, these inhibitors are not entirely BCR-ABL1-specific, and this lack of specificity could account for the off-target effects of these drugs. Adverse events (AEs) are off-target effects that are detrimental to the patient. The underlying mechanisms that contribute to these effects are poorly understood and the long-term consequences of chronic TKI therapy remain largely unknown, particularly with the newer agents. Here, we review the preclinical and clinical data for several of the more frequent AEs associated with TKIs and discuss the therapeutic relevance of these AEs for patients with CML.
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Affiliation(s)
- Juan Luis Steegmann
- Department of Hematology and Advanced Oncohematologic Therapies Group IIS-IP, Hospital Universitario de La Princesa, Madrid, Spain.
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197
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Dasanu CA, Padmanabhan P, Clark BA, Do C. Cardiovascular toxicity associated with small molecule tyrosine kinase inhibitors currently in clinical use. Expert Opin Drug Saf 2012; 11:445-57. [DOI: 10.1517/14740338.2012.672971] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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198
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Breccia M, Loglisci G, Salaroli A, Serrao A, Alimena G. Nilotinib-mediated increase in fasting glucose level is reversible, does not convert to type 2 diabetes and is likely correlated with increased body mass index. Leuk Res 2012; 36:e66-7. [DOI: 10.1016/j.leukres.2011.12.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 12/06/2011] [Accepted: 12/12/2011] [Indexed: 11/28/2022]
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199
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Valent P. Severe adverse events associated with the use of second-line BCR/ABL tyrosine kinase inhibitors: preferential occurrence in patients with comorbidities. Haematologica 2012; 96:1395-7. [PMID: 21972208 DOI: 10.3324/haematol.2011.052076] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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200
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Kim TD, le Coutre P, Schwarz M, Grille P, Levitin M, Fateh-Moghadam S, Giles FJ, Dörken B, Haverkamp W, Köhncke C. Clinical cardiac safety profile of nilotinib. Haematologica 2012; 97:883-9. [PMID: 22271904 DOI: 10.3324/haematol.2011.058776] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Nilotinib is a second-generation tyrosine kinase inhibitor with significant efficacy as first- or second-line treatment in patients with chronic myeloid leukemia. Despite preclinical evidence indicating a risk of prolongation of the QT interval, which was confirmed in clinical trials, detailed information on nilotinib's cardiac safety profile is lacking. DESIGN AND METHODS Here, we retrospectively assessed cardiovascular risk factors in 81 patients who were being or had previously been treated with nilotinib therapy and evaluated cardiovascular parameters by longitudinal monitoring of the QT interval and left ventricular ejection fraction. Detailed information on the occurrence and management of defined cardiac adverse events was extracted. RESULTS The median duration of nilotinib therapy was 26 months (range, 1-72). The median QT interval at baseline was 413 msec (range, 368-499 msec). During follow-up, the median QT was not significantly different from the baseline value at any time-point. Sixteen of 81 patients (20%) had new electrocardiographic changes. Cardiac function, as assessed by measurement of left ventricular ejection fraction, did not change significantly from baseline at any time-point. During a median follow-up of 44 months (range, 2-73), seven patients (9%), all of whom had received prior imatinib therapy, developed 11 clinical cardiac adverse events requiring treatment. The median time from the start of nilotinib therapy to an event was 14.5 months (range, 2-68). Five of seven patients were able to continue nilotinib therapy with only one brief interruption. CONCLUSIONS Whereas new electrocardiographic abnormalities were recorded in 20% of all patients and some of them developed severe or even life-threatening coronary artery disease, QT prolongation, changes in left ventricular ejection fraction, and clinical cardiac adverse events were uncommon in patients treated with nilotinib.
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Affiliation(s)
- Theo D Kim
- Medizinische Klinik mS Hämatologie und Onkologie, Charité -Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
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