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Hochman MJ, Vale CA, Hunter AM. SOHO State of the Art Updates and Next Questions | Choosing and Properly Using a JAK Inhibitor in Myelofibrosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)01804-4. [PMID: 39358153 DOI: 10.1016/j.clml.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 08/30/2024] [Accepted: 09/03/2024] [Indexed: 10/04/2024]
Abstract
Myelofibrosis (MF) is a chronic myeloid neoplasm characterized by myeloproliferation, bone marrow fibrosis, splenomegaly, and constitutional symptoms related to pro-inflammatory cytokine signaling. Biologically, MF is characterized by constitutive activation of JAK-STAT signaling; accordingly, JAK inhibitors have been rationally developed to treat MF. Following the initial approval of ruxolitinib in 2011, three additional agents have been approved: fedratinib, pacritinib, and momelotinib. As these therapies are noncurative, allogeneic stem cell transplantation remains a key treatment modality and patients with MF who are deemed candidates should be referred to a transplant center. This potentially curative but toxic approach is typically reserved for patients with higher-risk disease, and JAK inhibitors are recommended in the pretransplant setting. JAK inhibitors have proven effective at managing splenomegaly and constitutional symptoms and should be started early in the disease course in patients presenting with these clinical manifestations; asymptomatic patients may initially be followed with close surveillance. Drug-related myelosuppression has been a challenge with initial JAK inhibitors, particularly in patients presenting with a cytopenic phenotype. However, newer agents, namely pacritinib and momelotinib, have proven more effective in this setting and are approved for patients with significant thrombocytopenia and anemia, respectively. Resistance or disease progression is clinically challenging and may be defined by several possible events, such as increasing splenomegaly or progression to accelerated or blast phase disease. However, with multiple JAK inhibitors now approved, sequencing of these agents appears poised to improve outcomes. Additionally, novel JAK inhibitors and JAK inhibitor-based combinations are in clinical development.
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Affiliation(s)
- Michael J Hochman
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Colin A Vale
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Anthony M Hunter
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA.
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Harrison CN, Vannucchi AM, Recher C, Passamonti F, Gerds AT, Hernandez-Boluda JC, Yacoub A, Sirhan S, Ellis C, Patel B, Strouse B, Platzbecker U. Momelotinib versus Continued Ruxolitinib or Best Available Therapy in JAK Inhibitor-Experienced Patients with Myelofibrosis and Anemia: Subgroup Analysis of SIMPLIFY-2. Adv Ther 2024; 41:3722-3735. [PMID: 38990433 PMCID: PMC11349857 DOI: 10.1007/s12325-024-02928-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Some Janus kinase (JAK) inhibitors such as ruxolitinib and fedratinib do not address and may worsen anemia in patients with myelofibrosis. In these cases, the JAK inhibitor may be continued at a reduced dose in an effort to maintain splenic and symptom control, with supportive therapy and/or red blood cell (RBC) transfusions added to manage anemia. This post hoc descriptive analysis of the phase 3 SIMPLIFY-2 trial evaluated the relative benefits of this approach versus switching to the JAK1/JAK2/activin A receptor type 1 inhibitor momelotinib in patients for whom anemia management is a key consideration. METHODS SIMPLIFY-2 was a randomized (2:1), open-label, phase 3 trial of momelotinib versus best available therapy (BAT; 88.5% continued ruxolitinib) in JAK inhibitor-experienced patients with myelofibrosis (n = 156). Patient subgroups (n = 105 each) were defined by either baseline (1) hemoglobin (Hb) of < 100 g/L or (2) non-transfusion independence (not meeting the criteria of no transfusions and no Hb of < 80 g/L for the previous 12 weeks); outcomes have been summarized descriptively. RESULTS In both subgroups of interest, week 24 transfusion independence rates were higher with momelotinib versus BAT/ruxolitinib: baseline Hb of < 100 g/L, 22 (33.3%) versus 5 (12.8%); baseline non-transfusion independent, 25 (34.7%) versus 1 (3.0%). Mean Hb levels over time were also generally higher in both subgroups with momelotinib, despite median transfusion rates through week 24 with momelotinib being comparable to or lower than with BAT/ruxolitinib. Spleen and symptom response rates with momelotinib in these subgroups were comparable to the intent-to-treat population, while rates with BAT/ruxolitinib were lower. CONCLUSION In patients with moderate-to-severe anemia and/or in need of RBC transfusions, outcomes were improved by switching to momelotinib rather than continuing ruxolitinib and using anemia supportive therapies. TRIAL REGISTRATION ClinicalTrials.gov: NCT02101268.
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Affiliation(s)
- Claire N Harrison
- Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK.
| | | | | | - Francesco Passamonti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Dipartimento di Oncologia ed Onco-Ematologia, Università degli Studi di Milano, Milan, Italy
| | - Aaron T Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | | | | | - Shireen Sirhan
- Jewish General Hospital, McGill University, Montreal, QC, Canada
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Masarova L, Verstovsek S, Liu T, Rao S, Sajeev G, Fillbrunn M, Simpson R, Li W, Yang J, Lorier YL, Gorsh B, Signorovitch J. Transfusion-related cost offsets and time burden in patients with myelofibrosis on momelotinib vs. danazol from MOMENTUM. Future Oncol 2024:1-12. [PMID: 39072442 DOI: 10.1080/14796694.2024.2368450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/12/2024] [Indexed: 07/30/2024] Open
Abstract
Aim: To estimate projected US-based cost and time burden for patients with myelofibrosis and anemia treated with momelotinib compared with danazol. Methods: Cost and time burden were calculated based on the transfusion status of patients in the MOMENTUM trial and estimates extracted from previous studies. Results: Reductions in transfusion associated with momelotinib are projected to result in cost and time savings compared with danazol in transfusion-dependent and transfusion-independent/requiring patients with myelofibrosis, respectively: annual medical costs ($53,143 and $46,455 per person), outpatient transfusion costs ($42,021 and $8,370 per person) and annual time savings (173 and 35 h per person). Conclusion: Fewer transfusions with momelotinib are projected to result in cost and time savings in patients with myelofibrosis and anemia compared with danazol.
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Affiliation(s)
- Lucia Masarova
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer, Houston, TX 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer, Houston, TX 77030, USA
| | - Tom Liu
- GSK plc, Philadelphia, PA 19104, USA
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Gupta V, Oh S, Devos T, Dubruille V, Catalano J, Somervaille TCP, Platzbecker U, Giraldo P, Kosugi H, Sacha T, Mayer J, Illes A, Ellis C, Wang Z, Gonzalez Carreras FJ, Strouse B, Mesa R. Momelotinib vs. ruxolitinib in myelofibrosis patient subgroups by baseline hemoglobin levels in the SIMPLIFY-1 trial. Leuk Lymphoma 2024; 65:965-977. [PMID: 38501751 DOI: 10.1080/10428194.2024.2328800] [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] [Received: 01/31/2024] [Accepted: 03/03/2024] [Indexed: 03/20/2024]
Abstract
A key hallmark of myelofibrosis is anemia, which ranges from mild to severe based on hemoglobin levels. To more clearly define outcomes with the Janus kinase (JAK) 1/JAK2/activin A receptor type 1 inhibitor momelotinib by anemia severity, we performed a descriptive post hoc exploratory analysis of the double-blind, randomized, phase 3 SIMPLIFY-1 study (NCT01969838; N = 432, JAK inhibitor naive, momelotinib vs. ruxolitinib); subgroups were defined by baseline hemoglobin: <10 (moderate/severe), ≥10 to <12 (mild), or ≥12 g/dL (nonanemic). Spleen and symptom results were generally consistent with those previously reported for the intent-to-treat population. In anemic subgroups, momelotinib was associated with higher rates of transfusion independence and reduced/stable transfusion intensity vs. ruxolitinib. No new or unexpected safety signals were identified. Overall, momelotinib provides spleen, symptom, and anemia benefits to JAK inhibitor-naive patients with myelofibrosis regardless of baseline hemoglobin level, and greater anemia-related benefits vs. ruxolitinib in patients with hemoglobin <12 g/dL.
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Affiliation(s)
- Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, Canada
| | - Stephen Oh
- Washington University School of Medicine, St. Louis, MO, USA
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology (Rega Institute), KU Leuven, Leuven, Belgium
| | | | - John Catalano
- Monash University & Frankston Hospital, Frankston, Australia
| | - Tim C P Somervaille
- The Christie NHS Foundation Trust & Cancer Research UK Manchester Institute, Manchester, UK
| | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and Hemostaseology, University of Leipzig, Leipzig, Germany
| | - Pilar Giraldo
- Department of Hematology, Hospital Quironsalud, Zaragoza, Spain
| | - Hiroshi Kosugi
- Department of Hematology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Tomasz Sacha
- Jagiellonian University Hospital, Kraków, Poland
| | - Jiri Mayer
- University Hospital Brno, Brno, Czech Republic
| | - Arpad Illes
- Department of Internal Medicine, Division of Haematology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | | | | | | | | | - Ruben Mesa
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Kappenstein M, von Bubnoff N. Real-World Electronic Medical Records Data Identify Risk Factors for Myelofibrosis and Can Be Used to Validate Established Prognostic Scores. Cancers (Basel) 2024; 16:1416. [PMID: 38611094 PMCID: PMC11011132 DOI: 10.3390/cancers16071416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Myelofibrosis (MF) is a myeloproliferative neoplasia arising de novo as primary myelofibrosis (PMF) or secondary to polycythemia vera or essential thrombocythemia. Patients experience a high symptom burden and a marked reduction in life expectancy. Despite progress in molecular understanding and treatment, the clinical and prognostic heterogeneity of MF complicates treatment decisions. The International Prognostic Scoring System (IPSS) integrates clinical factors for risk stratification in MF. This study leverages the TriNetX database with more than 64,000 MF patients to assess the impact of accessible parameters on survival and complicating events, including AML transformation, cachexia, increased systemic inflammation, thrombosis and hemorrhage. Age over 65 years correlated with increased risks of death, AML transformation, thrombosis and hemorrhage. Anemia (Hb < 10 g/dL), leukocytosis (>25 × 103/µL) and thrombocytopenia (<150 × 103/µL) reduced survival and increased risks across all assessed events. Monocytosis is associated with decreased survival, whereas eosinophilia and basophilia were linked to improved survival. Further, as proof of concept for the applicability of TriNetX for clinical scores, we devised a simplified IPSS, and confirmed its value in predicting outcomes. This comprehensive study underscores the importance of age, anemia, leukocytosis and thrombocytopenia in predicting disease trajectory and contributes to refining prognostic models, addressing the challenges posed by the disease's heterogeneity.
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Affiliation(s)
| | - Nikolas von Bubnoff
- Medical Center, Department of Hematology and Oncology, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
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Ho YL, Gorycki P, Ferron‐Brady G, Martin P, Vlasakakis G. Clinical assessment of momelotinib drug-drug interactions via CYP3A metabolism and transporters. Clin Transl Sci 2024; 17:e13799. [PMID: 38634429 PMCID: PMC11024956 DOI: 10.1111/cts.13799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/05/2024] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Momelotinib-approved for treatment of myelofibrosis in adults with anemia-and its major active metabolite, M21, were assessed as drug-drug interaction (DDI) victims with a strong cytochrome P450 (CYP) 3A4 inhibitor (multiple-dose ritonavir), an organic anion transporting polypeptide (OATP) 1B1/1B3 inhibitor (single-dose rifampin), and a strong CYP3A4 inducer (multiple-dose rifampin). Momelotinib DDI perpetrator potential (multiple-dose) was evaluated with CYP3A4 and breast cancer resistance protein (BCRP) substrates (midazolam and rosuvastatin, respectively). DDI was assessed from changes in maximum plasma concentration (Cmax), area under the concentration-time curve (AUC), time to reach Cmax, and half-life. The increase in momelotinib (23% Cmax, 14% AUC) or M21 (30% Cmax, 24% AUC) exposure with ritonavir coadministration was not clinically relevant. A moderate increase in momelotinib (40% Cmax, 57% AUC) and minimal change in M21 was observed with single-dose rifampin. A moderate decrease in momelotinib (29% Cmax, 46% AUC) and increase in M21 (31% Cmax, 15% AUC) were observed with multiple-dose rifampin compared with single-dose rifampin. Due to potentially counteracting effects of OATP1B1/1B3 inhibition and CYP3A4 induction, multiple-dose rifampin did not significantly change momelotinib pharmacokinetics compared with momelotinib alone (Cmax no change, 15% AUC decrease). Momelotinib did not alter the pharmacokinetics of midazolam (8% Cmax, 16% AUC decreases) or 1'-hydroxymidazolam (14% Cmax, 16% AUC decreases) but increased rosuvastatin Cmax by 220% and AUC by 170%. Safety findings were mild in this short-term study in healthy volunteers. This analysis suggests that momelotinib interactions with OATP1B1/1B3 inhibitors and BCRP substrates may warrant monitoring for adverse reactions or dose adjustments.
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Huang H, Liu J, Yang L, Yan Y, Chen M, Li B, Xu Z, Qin T, Qu S, Wang L, Huang G, Chen Y, Xiao Z. Micheliolide exerts effects in myeloproliferative neoplasms through inhibiting STAT3/5 phosphorylation via covalent binding to STAT3/5 proteins. BLOOD SCIENCE 2023; 5:258-268. [PMID: 37941916 PMCID: PMC10629731 DOI: 10.1097/bs9.0000000000000168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/27/2023] [Indexed: 11/10/2023] Open
Abstract
Ruxolitinib is a cornerstone of management for some subsets of myeloproliferative neoplasms (MPNs); however, a considerable number of patients respond suboptimally. Here, we evaluated the efficacy of micheliolide (MCL), a natural guaianolide sesquiterpene lactone, alone or in combination with ruxolitinib in samples from patients with MPNs, JAK2V617F-mutated MPN cell lines, and a Jak2V617F knock-in mouse model. MCL effectively suppressed colony formation of hematopoietic progenitors in samples from patients with MPNs and inhibited cell growth and survival of MPN cell lines in vitro. Co-treatment with MCL and ruxolitinib resulted in greater inhibitory effects compared with treatment with ruxolitinib alone. Moreover, dimethylaminomicheliolide (DMAMCL), an orally available derivative of MCL, significantly increased the efficacy of ruxolitinib in reducing splenomegaly and cytokine production in Jak2V617F knock-in mice without evident effects on normal hematopoiesis. Importantly, MCL could target the Jak2V617F clone and reduce mutant allele burden in vivo. Mechanistically, MCL can form a stable covalent bond with cysteine residues of STAT3/5 to suppress their phosphorylation, thus inhibiting JAK/STAT signaling. Overall, these findings suggest that MCL is a promising drug in combination with ruxolitinib in the setting of suboptimal response to ruxolitinib.
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Affiliation(s)
- Huijun Huang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Jinqin Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Lin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Yiru Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Meng Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Bing Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Zefeng Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Tiejun Qin
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shiqiang Qu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Liang Wang
- State Key Laboratory of Medicinal Chemical Biology, College of Chemistry, Nankai University, 94 Weijin Road, Tianjin, China
| | - Gang Huang
- Department of Cell System & Anatomy, the University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Mays Cancer Center, Joe R. & Teresa Lozano Long School of Medicine, the University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Yue Chen
- State Key Laboratory of Medicinal Chemical Biology, College of Chemistry, Nankai University, 94 Weijin Road, Tianjin, China
| | - Zhijian Xiao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Hematologic Pathology Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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Gerds AT, Verstovsek S, Vannucchi AM, Al-Ali HK, Lavie D, Kuykendall AT, Grosicki S, Iurlo A, Goh YT, Lazaroiu MC, Egyed M, Fox ML, McLornan D, Perkins A, Yoon SS, Gupta V, Kiladjian JJ, Granacher N, Lee SE, Ocroteala L, Passamonti F, Harrison CN, Oh S, Klencke BJ, Yu J, Donahue R, Kawashima J, Mesa R. Momelotinib versus danazol in symptomatic patients with anaemia and myelofibrosis previously treated with a JAK inhibitor (MOMENTUM): an updated analysis of an international, double-blind, randomised phase 3 study. Lancet Haematol 2023; 10:e735-e746. [PMID: 37517413 DOI: 10.1016/s2352-3026(23)00174-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND The MOMENTUM study met all key endpoints at week 24, demonstrating symptom, spleen, and anaemia benefits with momelotinib versus danazol in patients with myelofibrosis. In this updated analysis, we report duration of week 24 responses and new responses with momelotinib through week 48. METHODS MOMENTUM is an international, double-blind, randomised, phase 3 study done at 107 sites across 21 countries. Patients were 18 years or older with primary, post-polycythaemia vera, or post-essential thrombocythaemia myelofibrosis, previously treated with an approved Janus kinase (JAK) inhibitor for 90 days or more (≥28 days with haematological complications), and had an Eastern Cooperative Oncology Group performance status of 2 or less. Patients were randomly assigned (2:1) to either the momelotinib group (200 mg orally once per day) or danazol group (300 mg orally twice per day) through week 24 via non-deterministic biased coin minimisation and an interactive response system. Stratification factors were Total Symptom Score (TSS; <22 vs ≥22), spleen size (<12 cm vs ≥12 cm), transfusion burden (0 units vs 1-4 units vs ≥5 units), and study site. After week 24, all patients initially randomly assigned to either group who remained on the study received open-label momelotinib. The primary endpoint, which has already been reported, was Myelofibrosis Symptom Assessment Form TSS response rate at week 24. Predefined secondary endpoints were duration of week 24 TSS and transfusion independence responses, safety, and survival, which are summarised post hoc at the week 48 data cutoff (May 17, 2022). TSS, transfusion independence, and splenic responses at week 48 were defined post hoc and assessed in all evaluable patients who entered the open-label period and provided sufficient data. The timing of this updated analysis was defined post hoc after all patients had the opportunity to complete their week 48 assessments, as most patients entered an extended access study (NCT03441113) after week 48. This study is registered with ClinicalTrials.gov, number NCT04173494, and is now complete. FINDINGS Between April 24, 2020, and Dec 3, 2021, a total of 195 patients were randomised (130 [67%] in the momelotinib group and 65 [33%] in the danazol group). 93 (72%) of 130 patients in the momelotinib group and 41 (63%) of 65 in the danazol group entered the momelotinib open-label extension period. Median follow-up was 48·4 weeks (IQR 40·6-55·7). Among TSS-evaluable patients at week 48, 30 (45%) of 67 patients in the momelotinib group who continued treatment and 15 (50%) of 30 in the danazol group who crossed over were responders. TSS responders at any time during the open-label period by week 48 were 46 (61%) of 75 evaluable patients in the momelotinib group who continued and 19 (59%) of 32 in the danazol group who crossed over, including most week 24 responders plus new responders after week 24. No new safety signals emerged with long-term follow-up. The most common non-haematological treatment-emergent adverse events in momelotinib-treated patients over the entire study period as of the data cutoff were diarrhoea (45 [26%] of 171) and asthenia (28 [16%]); the most common grades 3-4 treatment-emergent adverse events were thrombocytopenia (33 [19%]) and anaemia (19 [11%]). Serious treatment-emergent adverse events were reported in 79 (46%) of 171 patients, and fatal treatment-emergent adverse events were reported in 30 (18%); two fatal treatment-emergent adverse events were considered possibly related to momelotinib (rotaviral enteritis and Staphylococcus pneumonia). INTERPRETATION Momelotinib was associated with durable symptom, spleen, and anaemia benefits, late responses after week 24, and favourable safety through week 48. These results highlight the potential benefits of treatment with momelotinib in patients with myelofibrosis, particularly those with anaemia. FUNDING Sierra Oncology, a GSK company.
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Affiliation(s)
- Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandro M Vannucchi
- Department of Hematology, University of Florence, Florence, Italy; Center of Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy
| | | | - David Lavie
- Department of Hematology and Bone Marrow Transplantation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia, Katowice, Poland
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Mihaela C Lazaroiu
- Department of Hematology, Policlinica de Diagnostic Rapid Brasov, Brasov, Romania
| | - Miklos Egyed
- Department of Hematology, Somogy County Mór Kaposi General Hospital, Kaposvár, Hungary
| | - Maria Laura Fox
- Department of Haematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Donal McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Perkins
- Department of Haematology, Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, CIC1427, Paris, France
| | - Nikki Granacher
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Sung-Eun Lee
- Department of Hematology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | | | | | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stephen Oh
- Division of Hematology, Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | | | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Amé S, Barraco F, Ianotto J, Jourdan E, Rey J, Viallard J, Wémeau M, Kiladjian J. Advances in management of primary myelofibrosis and polycythaemia vera: Implications in clinical practice. EJHAEM 2023; 4:779-791. [PMID: 37601853 PMCID: PMC10435696 DOI: 10.1002/jha2.734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023]
Abstract
Primary myelofibrosis (PMF) and polycythaemia vera (PV) are rare BCR-ABL1-negative myeloproliferative neoplasms, associated with an increased risk of thrombosis, haemorrhagic complications and progression to fibrosis or leukaemia or fibrosis for PV. Both diseases are characterised by biological and clinical heterogeneity, leading to great variability in their management in routine clinical practice. In this review, we present an updated overview of the diagnosis, prognosis and treatment of PMF and PV, and we discuss how our multidisciplinary expert group based across France translates this evidence-based knowledge into routine clinical practice.
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Affiliation(s)
- Shanti Amé
- Department of HaematologyInstitut de Cancérologie Strasbourg Europe (ICANS)StrasbourgFrance
| | - Fiorenza Barraco
- Department of HaematologyLyon Sud Hospital CentrePierre‐BéniteFrance
| | | | - Eric Jourdan
- Department of Clinical HaematologyUniversity Hospital of NimesNimesFrance
| | - Jérôme Rey
- Department of HaematologyInstitute Paoli‐CalmettesMarseilleFrance
| | | | - Mathieu Wémeau
- Department of HaematologyHospital Centre of RoubaixRoubaixFrance
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10
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Chifotides HT, Verstovsek S, Bose P. Association of Myelofibrosis Phenotypes with Clinical Manifestations, Molecular Profiles, and Treatments. Cancers (Basel) 2023; 15:3331. [PMID: 37444441 PMCID: PMC10340291 DOI: 10.3390/cancers15133331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 07/15/2023] Open
Abstract
Myelofibrosis (MF) presents an array of clinical manifestations and molecular profiles. The two distinct phenotypes- myeloproliferative and myelodepletive or cytopenic- are situated at the two poles of the disease spectrum and are largely defined by different degrees of cytopenias, splenomegaly, and distinct molecular profiles. The myeloproliferative phenotype is characterized by normal/higher peripheral blood counts or mildly decreased hemoglobin, progressive splenomegaly, and constitutional symptoms. The myeloproliferative phenotype is typically associated with secondary MF, higher JAK2 V617F burden, fewer mutations, and superior overall survival (OS). The myelodepletive phenotype is usually associated with primary MF, ≥2 cytopenias, modest splenomegaly, lower JAK2 V617F burden, higher fibrosis, greater genomic complexity, and inferior OS. Cytopenias are associated with mutations in epigenetic regulators/splicing factors, clonal evolution, disease progression, and shorter OS. Clinical variables, in conjunction with the molecular profiles, inform integrated prognostication and disease management. Ruxolitinib/fedratinib and pacritinib/momelotinib may be more suitable to treat patients with the myeloproliferative and myelodepletive phenotypes, respectively. Appreciation of MF heterogeneity and two distinct phenotypes, the different clinical manifestations and molecular profiles associated with each phenotype alongside the growing treatment expertise, the development of non-myelosuppressive JAK inhibitors, and integrated prognostication are leading to a new era in patient management. Physicians can increasingly tailor personalized treatments that will address the unique unmet needs of MF patients, including those presenting with the myelodepletive phenotype, to elicit optimal outcomes and extended OS across the disease spectrum.
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Affiliation(s)
| | | | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (H.T.C.); (S.V.)
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11
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Chifotides HT, Masarova L, Verstovsek S. SOHO State of the Art Updates and Next Questions: Novel Therapeutic Strategies in Development for Myelofibrosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:219-231. [PMID: 36797153 PMCID: PMC10378306 DOI: 10.1016/j.clml.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023]
Abstract
Development of myelofibrosis (MF) therapeutics has reached fruition as the transformative impact of JAK2 inhibitors in the MPN landscape is complemented/expanded by a profusion of novel monotherapies and rational combinations in the frontline and second line settings. Agents in advanced clinical development span various mechanisms of action (eg, epigenetic or apoptotic regulation), may address urgent unmet clinical needs (cytopenias), increase the depth/duration of spleen and symptom responses elicited by ruxolitinib, improve other aspects of the disease besides splenomegaly/constitutional symptoms (eg, resistance to ruxolitinib, bone marrow fibrosis or disease course), provide personalized strategies, and extend overall survival (OS). Ruxolitinib had a dramatic impact on the quality of life and OS of MF patients. Recently, pacritinib received regulatory approval for severely thrombocytopenic MF patients. Momelotinib is advantageously poised among JAK inhibitors given its differentiated mode of action (suppression of hepcidin expression). Momelotinib demonstrated significant improvements in anemia measures, spleen responses, and MF-associated symptoms in MF patients with anemia; and will likely receive regulatory approval in 2023. An array of other novel agents combined with ruxolitinib, such as pelabresib, navitoclax, parsaclisib, or as monotherapies (navtemadlin) are evaluated in pivotal phase 3 trials. Imetelstat (telomerase inhibitor) is currently evaluated in the second line setting; OS was set as the primary endpoint, marking an unprecedented goal in MF trials, wherein SVR35 and TSS50 at 24 weeks have been typical endpoints heretofore. Transfusion independence may be considered another clinically meaningful endpoint in MF trials given its correlation with OS. Overall, therapeutics are at the cusp of an exponential expansion and advancements that will likely lead to the golden era in treatment of MF.
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Affiliation(s)
- Helen T Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
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12
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Rizwi FA, Abubakar M, Puppala ER, Goyal A, Bhadrawamy CV, Naidu VGM, Roshan S, Tazneem B, Almalki WH, Subramaniyan V, Rawat S, Gupta G. Janus Kinase-Signal Transducer and Activator of Transcription Inhibitors for the Treatment and Management of Cancer. J Environ Pathol Toxicol Oncol 2023; 42:15-29. [PMID: 37522565 DOI: 10.1615/jenvironpatholtoxicoloncol.2023045403] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
According to the World Health Organization (WHO), cancer is the second-highest cause of mortality worldwide, killing nearly 9.6 million people annually. Despite the advances in diagnosis and treatment during the last couple of decades, it remains a serious concern due to the limitations of currently available cancer management strategies. Therefore, alternative strategies are highly required to overcome these glitches. In addition, many etiological factors such as environmental and genetic factors initiate the activation of the Janus kinase (JAK)-signal transducer and activator of the transcription (STAT) pathway. This aberrant activation of the JAK-STAT pathway has been reported in various disease states, including inflammatory conditions, hematologic malignancies, and cancer. For instance, many patients with myeloproliferative neoplasms carry the acquired gain-of-function JAK2 V617F somatic mutation. This knowledge has dramatically improved our understanding of pathogenesis and has facilitated the development of therapeutics capable of suppressing the constitutive activation of the JAK-STAT pathway. Our aim is not to be expansive but to highlight emerging ideas towards preventive therapy in a modern view of JAK-STAT inhibitors. A series of agents with different specificities against different members of the JAK family of proteins is currently undergoing evaluation in clinical trials. Here we give a summary of how JAK-STAT inhibitors function and a detailed review of current clinical drugs for managing cancer as a new therapeutic approach.
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Affiliation(s)
- Fahim Anwar Rizwi
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research-Guwahati, Sila Katamur, Halugurisuk P.O-Changsari, Kamrup, Assam, India-781101
| | - Md Abubakar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research-Guwahati, Sila Katamur, Halugurisuk P.O-Changsari, Kamrup, Assam, India-781101
| | - Eswara Rao Puppala
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research-Guwahati, Sila Katamur, Halugurisuk P.O-Changsari, Kamrup, Assam, India-781101
| | - Ahsas Goyal
- Institute of Pharmaceutical Research, GLA University, Mathura, U.P., India
| | - Ch Veera Bhadrawamy
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research-Guwahati, Sila Katamur, Halugurisuk P.O-Changsari, Kamrup, Assam, India-781101
| | - V G M Naidu
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research-Guwahati, Sila Katamur, Halugurisuk P.O-Changsari, Kamrup, Assam, India-781101
| | - S Roshan
- Deccan School of Pharmacy, Hyderabad, India
| | - B Tazneem
- Deccan School of Pharmacy, Hyderabad, India
| | - Waleed Hassan Almalki
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Vetriselvan Subramaniyan
- Pharmacology Unit, Jeffrey Cheah School of Medicine and Health Sciences, MONASH University, Malaysia
| | - Sushama Rawat
- Nirma University, Institute of Pharmacy, Ahmedabad, Gujarat 382481, India; School of Pharmacy, Suresh Gyan Vihar University, Mahal Road, Jagatpura 302017, Jaipur, India
| | - Gaurav Gupta
- School of Pharmacy, Suresh Gyan Vihar University, Mahal Road, Jagatpura 302017, Jaipur, India; Department of Pharmacology, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India; Uttaranchal Institute of Pharmaceutical Sciences, Uttaranchal University, Dehradun, India
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13
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Zhang Y, Zhou H, Jiang Z, Wu D, Zhuang J, Li W, Jiang Q, Wang X, Huang J, Zhu H, Yang L, Du X, Li F, Xia R, Zhang F, Hu J, Li Y, Hu Y, Liu J, Jin C, Sun K, Zhou Z, Wu L, Yu W, Jin J. Safety and efficacy of jaktinib in the treatment of Janus kinase inhibitor-naïve patients with myelofibrosis: Results of a phase II trial. Am J Hematol 2022; 97:1510-1519. [PMID: 36054786 PMCID: PMC10092883 DOI: 10.1002/ajh.26709] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 01/31/2023]
Abstract
Myelofibrosis (MF) is associated with several constitutional symptoms. Currently, there are few therapeutic options for MF. Jaktinib, a novel, small-molecule inhibitor of JAK, is currently being studied for its potential to treat MF. This phase 2 trial investigated efficacy and safety of jaktinib in the treatment of MF patients. The primary end point was the proportion of patients with ≥35% reduction in spleen volume (SVR35, proportion of patients with ≥35% reduction in spleen volume) at week 24. The secondary end points included improvement of anemia, rates of symptom response, and safety profile. Between January 8, 2019 and August 29, 2020, 118 patients were recruited and treated with either jaktinib 100 mg BID or 200 mg QD. At week 24, 54.8% (34/62) of patients in the 100 mg BID group and 31.3% (15/48) in the 200 mg QD group achieved SVR35 (p = .0199). Jaktinib treatment increased hemoglobin level to ≥20 g/L in 35.6% (21/59) of patients with hemoglobin ≤100 g/L at baseline. The proportion of patients who achieved a ≥50% improvement in total symptom score at week 24 was 69.6% (39/56) in the BID group and 57.5% (23/40) in the QD group. The most common ≥ grade 3 hematological treatment-emergent adverse events (TEAEs; ≥ 10%) were anemia (100 mg BID: 24.2%, 200 mg QD: 28.8%), thrombocytopenia (16.7%, 11.5%), and neutropenia (3.0%, 11.5%). All non-hematological TEAEs were mild. These results indicate that jaktinib can shrink the spleen, improve anemia, and other clinical symptoms with good tolerability.
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Affiliation(s)
- Yi Zhang
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China.,Zhejiang Provincial Key Laboratory of Hematopoietic Malignancy, Zhejiang University, Hangzhou, P.R. China.,Zhejiang Provincial Clinical Research Center for Hematological Disorders, Hangzhou, P.R. China.,Zhejiang University Cancer Center, Hangzhou, P.R. China
| | - Hu Zhou
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, P.R. China
| | - Zhongxing Jiang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, P.R. China
| | - Dengshu Wu
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Junling Zhuang
- Department of Hematology, Peking Union Medical College Hospital (Dongdan Campus), Beijing, P.R. China
| | - Wei Li
- Department of Hematology, Cancer Center, The First Hospital of Jilin University, Changchun, P.R. China
| | - Qian Jiang
- Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell, Beijing, P.R. China
| | - Xiuli Wang
- Department of Oncology Hematology, The Second Hospital of Jilin University, Changchun, P.R. China
| | - Jinwen Huang
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Huanling Zhu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Linhua Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, P.R. China
| | - Xin Du
- Department of Hematology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China
| | - Fei Li
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Ruixiang Xia
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Feng Zhang
- Department of Hematology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, P.R. China
| | - Jianda Hu
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, P.R. China
| | - Yan Li
- Department of Hematopathology, The First Hospital of China Medical University, Shenyang, P.R. China
| | - Yu Hu
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Jing Liu
- Department of Hematology, Third Xiangya Hospital of Central South University, Changsha, P.R. China
| | - Chenghao Jin
- Department of Hematology, Jiangxi Provincial People's Hospital, Nanchang, P.R. China
| | - Kai Sun
- Department of Hematology, Henan Provincial People's Hospital, Zhengzhou, P.R. China
| | - Zeping Zhou
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, P.R. China
| | - Liqing Wu
- Suzhou Zelgen Biopharmaceuticals Co, Ltd, Suzhou, P.R. China
| | - Wenjuan Yu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China.,Zhejiang Provincial Key Laboratory of Hematopoietic Malignancy, Zhejiang University, Hangzhou, P.R. China.,Zhejiang Provincial Clinical Research Center for Hematological Disorders, Hangzhou, P.R. China.,Zhejiang University Cancer Center, Hangzhou, P.R. China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China.,Zhejiang Provincial Key Laboratory of Hematopoietic Malignancy, Zhejiang University, Hangzhou, P.R. China.,Zhejiang Provincial Clinical Research Center for Hematological Disorders, Hangzhou, P.R. China.,Zhejiang University Cancer Center, Hangzhou, P.R. China
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14
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Chifotides HT, Bose P, Masarova L, Pemmaraju N, Verstovsek S. SOHO State of the Art Updates and Next Questions: Novel Therapies in Development for Myelofibrosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:210-223. [PMID: 34840087 DOI: 10.1016/j.clml.2021.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 06/13/2023]
Abstract
Myeloproliferative neoplasms research has entered a dynamic and exciting era as we witness exponential growth of novel agents in advanced/early phase clinical trials for myelofibrosis (MF). Building on the success and pivotal role of ruxolitinib, many novel agents, spanning a wide range of mechanisms/targets (epigenetic regulation, apoptotic/intracellular signaling pathways, telomerase, bone marrow fibrosis) are in clinical development; several are studied in registrational trials and hold great potential to expand the therapeutic arsenal/shift the treatment paradigm if regulatory approval is granted. Insight into MF pathogenesis and its molecular underpinnings, preclinical studies demonstrating synergism of ruxolitinib with investigational agents, urgent unmet clinical needs (cytopenias, loss of response to JAK inhibitors); and progressive disease fueled the rapid rise of innovative therapeutics. New strategies include pairing ruxolitinib with erythroid maturation agents to manage anemia (luspatercept), designing rational combinations with ruxolitinib to boost responses in both the frontline and suboptimal response settings (pelabresib, navitoclax, parsaclisib), treatment with non-JAK inhibitor monotherapy in the second-line setting (navtemadlin, imetelstat), novel JAK inhibitors tailored to subgroups with challenging unmet needs (momelotinib and pacritinib for anemia and thrombocytopenia, respectively); and agents potentially enhancing longevity (imetelstat). Beyond typical endpoints evaluated in MF clinical trials (spleen volume reduction ≥ 35%, total symptom score reduction ≥ 50%) thus far, emerging endpoints include overall survival, progression-free survival, transfusion independence, anemia benefits, bone marrow fibrosis and driver mutation allele burden reduction. Novel biomarkers and additional clinical features are being sought to assess new agents and tailor emerging therapies to appropriate patients. New strategies are needed to optimize the design of clinical trials comparing novel combinations to standard agent monotherapy.
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Affiliation(s)
- Helen T Chifotides
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Lucia Masarova
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX.
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15
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Chifotides HT, Bose P, Verstovsek S. Momelotinib: an emerging treatment for myelofibrosis patients with anemia. J Hematol Oncol 2022; 15:7. [PMID: 35045875 PMCID: PMC8772195 DOI: 10.1186/s13045-021-01157-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 12/11/2022] Open
Abstract
The suite of marked anemia benefits that momelotinib has consistently conferred on myelofibrosis (MF) patients stem from its unique inhibitory activity on the BMP6/ACVR1/SMAD and IL-6/JAK/STAT3 pathways, resulting in decreased hepcidin (master iron regulator) expression, higher serum iron and hemoglobin levels, and restored erythropoiesis. Clinical data on momelotinib from the phase 2 and the two phase 3 SIMPLIFY trials consistently demonstrated high rates of sustained transfusion-independence. In a recent phase 2 translational study, 41% of the patients achieved transfusion independence for ≥ 12 weeks. In the phase 3 trials SIMPLIFY-1 and SIMPLIFY-2, 17% more JAK inhibitor-naïve patients and two-fold more JAK inhibitor-treated patients achieved or maintained transfusion independence with momelotinib versus ruxolitinib and best available therapy (89% ruxolitinib), respectively. Anemia is present in approximately a third of MF patients at diagnosis, eventually developing in nearly all patients. The need for red blood cell transfusions is an independent adverse risk factor for both overall survival and leukemic transformation. Presently, FDA-approved medications to address anemia are lacking. Momelotinib is one of the prime candidates to durably address the critical unmet needs of MF patients with moderate/severe anemia. Importantly, momelotinib may have overall survival benefits in frontline and second-line MF patients. MOMENTUM is an international registration-track phase 3 trial further assessing momelotinib’s unique constellation of anemia and other benefits in second-line MF patients; the results of the MOMENTUM trial are keenly awaited and may lead to regulatory approval of momelotinib.
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16
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Retrospective Analysis of the Clinical Use and Benefit of Lenalidomide and Thalidomide in Myelofibrosis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e956-e960. [DOI: 10.1016/j.clml.2020.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022]
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17
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Bose P, Verstovsek S. Management of myelofibrosis after ruxolitinib failure. Leuk Lymphoma 2020; 61:1797-1809. [PMID: 32297800 PMCID: PMC8565616 DOI: 10.1080/10428194.2020.1749606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/16/2020] [Accepted: 03/25/2020] [Indexed: 12/12/2022]
Abstract
Over the last decade, the Janus kinase1/2 (JAK1/2) inhibitor ruxolitinib has emerged as a cornerstone of myelofibrosis (MF) management. Ruxolitinib improves splenomegaly and symptoms regardless of driver mutation status, and confers a survival advantage in patients with intermediate-2/high risk MF. However, cytopenias remain problematic, and evidence for a robust anti-clonal effect is lacking. Furthermore, the median duration of spleen response to ruxolitinib in clinical trials is approximately 3 years, and ruxolitinib does not appear to affect the risk of leukemic transformation. There is no therapy approved specifically for patients whose disease 'progresses' on ruxolitinib, defining which remains challenging. The recent regulatory approval of the JAK2 inihibitor fedratinib partially fulfills this unmet need, but much remains to be done. Other JAK inhibitors and a plethora of novel agents are being studied in the ruxolitinib 'failure' setting, as well as 'add-on' therapies to ruxolitinib in patients having a 'sub-optimal' response.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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18
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Li Y, Zhu S, Liu W, Ming J, Wang X, Hu X. Ruxolitinib-based combinations in the treatment of myelofibrosis: worth looking forward to. Ann Hematol 2020; 99:1161-1176. [PMID: 32333155 PMCID: PMC7237512 DOI: 10.1007/s00277-020-04028-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
Abstract
Ruxolitinib is a targeted drug to treat myelofibrosis (MF). Ruxolitinib has significant advantages in spleen reduction and increasing 5-year overall survival (OS), and ruxolitinib-based combinations might provide more benefits than ruxolitinib monotherapy. In this review, we focus on the data of ruxolitinib-based combinations therapies and treatment-related adverse events (AEs) and safety. We analyzed and summarized the data of ruxolitinib-based combinations. Ruxolitinib combined with prednisone + thalidomide + danazol (TPD), panobinostat, pracinostat, azacytidine, or hydroxyurea has well reduced spleen. Ruxolitinib combined with danazol or TPD had well therapies in improvement of hemoglobin (Hgb) and platelets (PLT). Most ruxolitinib-based combinations therapies showed a superior benefit on reduced treatment-related AEs than ruxolitinib monotherapy. Treatment-related AEs and dose modification affect the safety and tolerability of ruxolitinib-based combinations. Genetic testing before treatment is recommended. To provide better clinical guidance, comparisons of these randomized controlled trials with the trials of ruxolitinib alone are necessary. This review suggests that the clinical application of ruxolitinib-based combinations is worth waiting for.
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Affiliation(s)
- Yujin Li
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091 China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Shirong Zhu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091 China
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029 China
| | - Weiyi Liu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091 China
| | - Jing Ming
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091 China
| | - Xueying Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091 China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Xiaomei Hu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091 China
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19
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Iurlo A, Cattaneo D, Bucelli C. Management of Myelofibrosis: from Diagnosis to New Target Therapies. Curr Treat Options Oncol 2020; 21:46. [DOI: 10.1007/s11864-020-00734-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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20
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Caocci G, Simula MP, Ghiani S, Mulas O, Mainas G, Atzeni S, Pettinau M, Usala E, La Nasa G. Increased incidence of infection in patients with myelofibrosis and transfusion-associated iron overload in the clinical setting. Int J Hematol 2020; 111:614-618. [PMID: 32207052 DOI: 10.1007/s12185-020-02861-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 12/15/2022]
Abstract
Transfusion-associated iron overload may lead to increased risk of infection, but its role in myelofibrosis (MF) has been scarcely explored. We evaluated 106 consecutive patients with primary or secondary MF. Up to 38% of patients were transfusion-dependent (TD) with a median of 14 RBC units received. Median observation time was 36 months (range 3-203). Forty-five percent of patients experienced one or more infectious episodes for a total of 69 infectious events, 13 (19%) of which were severe. The 60-month cumulative incidence of infection was 64.1 ± 6.5%. TD patients showed a higher incidence of infection (HR = 2.13, p = 0.019). Transfusion burden was markedly greater in TD patients with infectious complication (median 24 RBC units vs 15 RBC units; p = 0.012). The 60-month overall survival was 40 ± 5.9%. Lower International Prognostic Scoring System (IPSS) risk (p < 0.0001) and ruxolitinib (p = 0.027) were significantly correlated with higher survival. This real-world study showed increased infections in patients with higher transfusion burden. It may therefore be interesting to further investigate the role of iron chelation in improving infection-free survival in MF patients.
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Affiliation(s)
- Giovanni Caocci
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy.
| | - Maria Pina Simula
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy
| | - Silvia Ghiani
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy
| | - Olga Mulas
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy
| | - Giorgia Mainas
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy
| | - Sandra Atzeni
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy
| | - Martina Pettinau
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy
| | - Emilio Usala
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy
| | - Giorgio La Nasa
- SC Ematologia e CTMO, Ospedale Businco, AOB, Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Via Jenner, sn, 09124, Cagliari, Italy
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Bose P. Advances in potential treatment options for myeloproliferative neoplasm associated myelofibrosis. Expert Opin Orphan Drugs 2019; 7:415-425. [PMID: 33094033 PMCID: PMC7577425 DOI: 10.1080/21678707.2019.1664900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The Janus kinase (JAK)1/2 inhibitor ruxolitinib provides rapid, sustained and often dramatic benefits to patients with myelofibrosis, inducing spleen shrinkage and ameliorating symptoms, and improves survival. However, the drug has little effect on the underlying bone marrow fibrosis or on mutant allele burden, and clinical resistance eventually develops. Furthermore, ruxolitinib-induced cytopenias can be challenging in everyday practice. AREAS COVERED The developmental therapeutics landscape in MF is discussed. This includes potential partners for ruxolitinib being developed with an aim to improve cytopenias, or to enhance its disease-modifying effects. The development of other JAK inhibitors with efficacy post-ruxolitinib or other unique attributes is being pursued in earnest. Agents with novel mechanisms of action are being studied in patients whose disease responds sub-optimally to, is refractory to or progresses after ruxolitinib. EXPERT OPINION The JAK inhibitors fedratinib, pacritinib and momelotinib are clearly active, and it is expected that one or more of these will become licensed in the future. The activin receptor ligand traps are promising as treatments for anemia. Imetelstat has shown interesting activity post-ruxolitinib, and azactidine may be a useful partner for ruxolitinib in some patients. Appropriately, multiple pre-clinical and clinical leads are being pursued in this difficult therapeutic area.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Transforming growth factor (TGF)-β pathway as a therapeutic target in lower risk myelodysplastic syndromes. Leukemia 2019; 33:1303-1312. [PMID: 30962581 DOI: 10.1038/s41375-019-0448-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/17/2019] [Accepted: 03/01/2019] [Indexed: 01/08/2023]
Abstract
The transforming growth factor (TGF)-β superfamily comprises more than 30 soluble growth factors that play a central role in erythropoiesis and are part of a tightly regulated myelosuppressive negative feedback loop under physiologic conditions. TGF-β receptor activation and phosphorylation trigger a regulatory circuit of activating and inhibitory SMAD proteins and increased activation of the TGF-β signaling pathway either by a loss of negative feedback or constitutive activation has been associated with the myelosuppression and ineffective erythropoiesis in myelodysplastic syndromes (MDS). Anemia is the predominant cause of morbidity and quality of life impairment in patients with lower-risk (LR)-MDS, and there are very limited therapy options for these patients after failure of erythropoiesis stimulating agents (ESAs). Targeting the aberrant TGF-ß signaling pathway has therefore been investigated as a promising therapeutic approach to resolve the ineffective erythropoiesis in LR-MDS. In this article, we provide a brief overview of the TGF-β signaling cascade in hematopoiesis under physiologic conditions and its role in MDS pathogenesis. We also review preclinical and clinical data for the activin receptor type IIA ligand traps sotatercept and luspatercept that have recently shown promising results in overcoming the myelosuppressive effects of TGF-β signaling alterations to improve hematopoiesis in transfusion-dependent, non-del(5q) LR-MDS patients. Additional potential targets within the TGF-β pathway have also been identified in preclinical experiments and may provide further therapeutic options. Finally, combining different TGF-β pathway inhibitors or using them in combination with ESAs or the immunomodulator lenalidomide might have synergistic effects as well.
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Abstract
OPINION STATEMENT Seven years after the approval of the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib, it remains the only drug licensed for the treatment of myelofibrosis. Patients who discontinue ruxolitinib have a dismal outcome, and this is, therefore, an area of significant unmet need. Given the central role that JAK-signal transducer and activator of transcription (STAT) activation plays in disease pathogenesis, there have been many other JAK inhibitors tested, but most have been abandoned, for a variety of reasons. The JAK2-selective inhibitor fedratinib has recently been resurrected, and there has been a resurgence of interest in the failed JAK1/2 inhibitor momelotinib, which possibly improves anemia. Pacritinib, a non-myelosuppressive JAK2-selective inhibitor, is currently in a dose-ranging study mandated by regulatory authorities. A plethora of other targeted agents, most backed by preclinical data, are in various stages of investigation. These include epigenetic and immune therapies, agents targeting cellular survival, metabolic and apoptotic pathways, the cell cycle, DNA repair, and protein folding and degradation, among others. However, at this time, none of these is close to registration or even in a pivotal trial, illustrating the difficulties in recapitulating the clinical disease in preclinical models. Most current clinical trials are testing the addition of a novel agent to ruxolitinib, either in the frontline setting or in the context of an insufficient response to ruxolitinib, or attempting to study new drugs in the second-line, "ruxolitinib failure" setting. Emerging data supports the addition of azacitidine to ruxolitinib in some patients. Other strategies have focused on improving cytopenias, through amelioration of bone marrow fibrosis or other mechanisms. This is important, because cytopenias are the commonest reason for ruxolitinib interruption and/or dose reduction, and dose optimization of ruxolitinib is tied to its survival benefit. The activin receptor ligand trap, sotatercept, and the anti-fibrotic agent, PRM-151, have shown promise in this regard.
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