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Takahashi N, Kondo T, Ikari Y, Fukumoto Y, Hatake K, Masunari A, Nishibayashi S, Kageyama A, Fukuta Y, Tojo A. Real-world outcomes of ponatinib treatment in 724 patients with CML and Ph+ ALL: a post-marketing surveillance study with a special interest in arterial occlusive events in Japan. Jpn J Clin Oncol 2024; 54:930-938. [PMID: 38747937 PMCID: PMC11322879 DOI: 10.1093/jjco/hyae061] [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: 12/20/2023] [Accepted: 05/01/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND In September 2016, ponatinib was approved in Japan for the treatment of patients with chronic myeloid leukemia with resistance/intolerance to prior tyrosine kinase inhibitors and patients with relapsed or refractory Philadelphia chromosome-positive acute lymphoblastic leukemia. METHODS We conducted a post-marketing all-case surveillance to study the safety and efficacy of ponatinib in clinical practice, focusing on arterial occlusive events. RESULTS Data from 724 patients were collected for 2 years from the initiation of ponatinib. The arterial occlusive events were reported in 6.49% (47/724) with an exposure-adjusted incidence rate of 6.8/100 person-years. The risks associated with arterial occlusive events were age and comorbidities including hypertension and diabetes. At 104 weeks, the cumulative major molecular response rate in patients with chronic-phase chronic myeloid leukemia was 67.2% and the complete cytogenetic response in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia was 80.0%. Furthermore, the estimated 1-year overall survival rate was 98.5% for chronic-phase chronic myeloid leukemia and 68.6% for Philadelphia chromosome-positive acute lymphoblastic leukemia. CONCLUSIONS This surveillance demonstrated that ponatinib has a favorable safety and efficacy profile in Japanese patients and also showed the necessity of closely monitoring arterial occlusive events in older adults and patients with predisposing factors for atherosclerosis.
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Affiliation(s)
- Naoto Takahashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Takeshi Kondo
- Department of Hematology, Blood Disorders Center, Aiiku Hospital, Sapporo, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University Hospital, Isehara, Japan
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Kiyohiko Hatake
- Department of Lymphoma/Hematology Center, Mita Hospital, International University of Health and Welfare, Tokyo, Japan
| | | | | | | | | | - Arinobu Tojo
- Tokyo Medical and Dental University, Tokyo, Japan
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Kantarjian HM, Chifotides HT, Haddad FG, Short NJ, Loghavi S, Jabbour E. Ponatinib-review of historical development, current status, and future research. Am J Hematol 2024; 99:1576-1585. [PMID: 38727135 PMCID: PMC11233239 DOI: 10.1002/ajh.27355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/12/2024] [Accepted: 04/26/2024] [Indexed: 07/10/2024]
Abstract
Ponatinib is a third-generation BCR::ABL1 tyrosine kinase inhibitor (TKI) with high potency against Philadelphia chromosome (Ph)-positive leukemias, including T315I-mutated disease, which is resistant to first- and second-generation TKIs. Ponatinib was approved for T315I-mutated chronic myeloid leukemia (CML), CML resistant/intolerant to ≥2 prior TKIs, advanced phase CML and Ph-positive acute lymphoblastic leukemia (ALL) where no other TKIs are indicated, and T315I-mutated CML and Ph-positive ALL. The response-based dosing of ponatinib in chronic phase CML (CP-CML) improved treatment tolerance and reduced the risk of toxicities, including cardiovascular risks. Ponatinib-based therapy also resulted in significantly better outcomes in frontline Ph-positive ALL compared with prior TKIs and is becoming a new standard of care in this setting. As the clinical development of third-generation TKIs and their rational combinations progresses, we envision further transformative changes in the treatment of CML and Ph-positive ALL.
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Affiliation(s)
- Hagop M. Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston TX, USA
| | - Helen T. Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston TX, USA
| | - Fadi G. Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston TX, USA
| | - Nicholas J. Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston TX, USA
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George B, Chan KH, Rios A. Therapeutic options for chronic myeloid leukemia following the failure of second-generation tyrosine kinase inhibitor therapy. Front Oncol 2024; 14:1446517. [PMID: 39139284 PMCID: PMC11320603 DOI: 10.3389/fonc.2024.1446517] [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: 06/10/2024] [Accepted: 07/15/2024] [Indexed: 08/15/2024] Open
Abstract
The management of chronic myeloid leukemia in the chronic phase (CML-CP) has witnessed significant advancements since the identification of a common chromosomal translocation anomaly involving chromosomes 9 and 22, which results in the formation of the Philadelphia chromosome driven by the BCR-ABL1 fusion protein. This discovery paved the way for the development of tyrosine kinase inhibitors (TKIs) that target the adenosine triphosphate (ATP) binding site of ABL1 through the BCR-ABL-1 fusion protein. Following the approval of Imatinib by the Food and Drug Administration (FDA) as the first TKI for CML treatment in 2001, the median overall survival (OS) for chronic phase CML (CML-CP) has significantly improved, approaching that of the general population. However, achieving this milestone crucially depends on reaching certain treatment response milestones. Since the introduction of imatinib, five additional TKIs have been approved for CML-CP treatment. Despite the availability of these treatments, many patients may experience treatment failure and require multiple lines of therapy due to factors such as the emergence of resistance, such as mutations in the ATP binding site of ABL, or intolerance to therapy. This review will primarily focus on exploring treatment options for patients who fail second-generation TKI therapy due to true resistance.
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Affiliation(s)
- Binsah George
- Division of Hematology/Oncology, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States
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4
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Mulas O, Abruzzese E, Luciano L, Iurlo A, Attolico I, Castagnetti F, Galimberti S, Bonifacio M, Annunziata M, Gozzini A, Orlandi EM, Stagno F, Binotto G, Pregno P, Fozza C, Loi M, Trawinska MM, De Gregorio F, Cattaneo D, Albano F, Iezza M, Baratè C, Scaffidi L, Elena C, Giai V, Scalzulli E, Breccia M, La Nasa G, Caocci G. The new Systematic Coronary Risk Evaluation (SCORE2 and SCORE2-OP) estimates the risk of arterial occlusive events in chronic myeloid leukemia patients treated with nilotinib or ponatinib. Ann Hematol 2024; 103:427-436. [PMID: 38012435 PMCID: PMC10798925 DOI: 10.1007/s00277-023-05556-0] [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: 08/25/2023] [Accepted: 11/19/2023] [Indexed: 11/29/2023]
Abstract
Patients with chronic myeloid leukemia (CML) treated with nilotinib or ponatinib may experience arterial occlusive events (AOEs). It is currently recommended to thoroughly assess cardiovascular risk factors before treating CML. We identified 455 consecutive CML adult patients, 335 treated with nilotinib and 120 with ponatinib; 380 patients without previous cardiovascular diseases or diabetes were stratified according to the Systematic Coronary Risk Evaluation (SCORE2) and SCORE2-Older Persons (SCORE2-OP). This updated algorithm from the European Society of Cardiology (ESC) estimates a 10-year risk of fatal and non-fatal cardiovascular diseases. It is based on sex, age, smoking habits, systolic blood pressure, non-high-density lipoprotein cholesterol, and European geographical region of cardiovascular risk. The SCORE2/SCORE2-OP algorithm translated more patients (50.2%) to the high-very high cardiovascular risk category than the previous SCORE (25.3%). Patients with a high to very high SCORE2/SCORE2-OP risk showed a significantly higher incidence rate of AOEs (69.2% vs. 46.5%, p < 0.001). The older SCORE was less specific in estimating AOEs in patients classified as low-intermediate risk (69.8 vs. 54.2%). In multivariate analysis, no associations were found between AOEs and gender, age, and type or dose of tyrosine kinase inhibitor. Only the SCORE2/SCORE2-OP risk was confirmed as a significant predictive factor (p = 0.028; hazard ratio = 2.2; 95% confidence interval = 1.1-4.5). Patients with AOEs required, in most cases, imaging diagnostic tests, additional drugs, and sometimes invasive procedures, increasing access to visits and hospital management. This real-life study suggested that the SCORE2 and SCORE2-OP charts could help identify cardiovascular fragility in CML patients providing them with more attention and a proper TKI selection.
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MESH Headings
- Adult
- Humans
- Aged
- Aged, 80 and over
- Cardiovascular Diseases/chemically induced
- Cardiovascular Diseases/epidemiology
- Cardiovascular Diseases/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/epidemiology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/chemically induced
- Imidazoles/adverse effects
- Pyrimidines/therapeutic use
- Protein Kinase Inhibitors/adverse effects
- Pyridazines
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Affiliation(s)
- Olga Mulas
- Department of Medical Sciences and Public Health, Hematology Unit, Businco Hospital, University of Cagliari, Cagliari, Italy
| | | | - Luigiana Luciano
- Hematology Unit "Federico II", University of Naples, Naples, Italy
| | - Alessandra Iurlo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Immacolata Attolico
- Hematology and Stem Cell Transplantation Unit, Azienda Ospedaliero-Universitaria-Consorziale (AOUC) - Policlinico, Bari, Italy
| | - Fausto Castagnetti
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | | | | | - Antonella Gozzini
- Hematology Unit, AOU Careggi, University of Florence, Florence, Italy
| | - Ester Maria Orlandi
- Division of Hematology, Fondazione IRCCS Policlinico S. Matteo", Pavia, Italy
| | - Fabio Stagno
- Hematology Unit, AOU Policlinico - V. Emanuele, Rodolico Hospital, Catania, Italy
| | | | - Patrizia Pregno
- Hematology Unit, Azienda Ospedaliero-Universitaria Città Della Salute E Della Scienza, Turin, Italy
| | - Claudio Fozza
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Maurizio Loi
- Department of Medical Sciences and Public Health, Hematology Unit, Businco Hospital, University of Cagliari, Cagliari, Italy
| | | | | | - Daniele Cattaneo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Albano
- Hematology and Stem Cell Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", Bari, Italy
| | - Miriam Iezza
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudia Baratè
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Luigi Scaffidi
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Chiara Elena
- Division of Hematology, Fondazione IRCCS Policlinico S. Matteo", Pavia, Italy
| | - Valentina Giai
- Hematology Unit, Azienda Ospedaliero-Universitaria Città Della Salute E Della Scienza, Turin, Italy
| | - Emilia Scalzulli
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | - Giorgio La Nasa
- Department of Medical Sciences and Public Health, Hematology Unit, Businco Hospital, University of Cagliari, Cagliari, Italy
| | - Giovanni Caocci
- Department of Medical Sciences and Public Health, Hematology Unit, Businco Hospital, University of Cagliari, Cagliari, Italy.
- SC Ematologia E CTMO, Ospedale Businco, Dipartimento di Scienze Mediche e Sanità Pubblica, Università Di Cagliari, Via Jenner, Sn, 09124, Cagliari, Italy.
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Zhang S, Lai H, Chen H, Wang J, Tu H, Li J. Comparative efficacy and safety of different doses of ponatinib versus other tyrosine kinase inhibitors for the treatment of chronic myeloid leukemia: a systematic review and network meta-analysis. Expert Opin Drug Saf 2024; 23:37-45. [PMID: 37852954 DOI: 10.1080/14740338.2023.2273339] [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: 05/29/2023] [Accepted: 09/15/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE Ponatinib was recommended with caution because of its high risk of causing arterial occlusion events in chronic myeloid leukemia (CML) patients. The purpose of this study was to understand the efficacy and safety of different doses of ponatinib in the treatment of CML, and to compare it with other tyrosine kinase inhibitors (TKIs). METHOD A network meta-analysis (NMA) was conducted by searching randomized controlled trials (RCTs) of ponatinib in patients with CML to compare the efficacy and safety of ponatinib, and ranked under the cumulative ranking curve (SUCRA) to evaluate the optimal treatment. RESULTS A total of seven articles with eight RCTs were included in this study, involving 45 mg, 30 mg and 15 mg ponatinib doses. Seven outcome indexes were analyzed. The results showed that 45 mg ponatinib was superior to other doses of ponatinib and other TKIs in CCyR, MCyR and CHR, but the incidence of SAEs and AOEs was significantly higher than other treatment regimens. CONCLUSION Ponatinib, with an initial dosage of 45 mg and a gradual reduction to 15 mg, may be a more favorable option for patients with CML at all stages of disease progression, rather than just those in the chronic phase of CML.
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Affiliation(s)
- Shan Zhang
- The Key Laboratory of Hematology of Jiangxi Province, The Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Hurong Lai
- The Key Laboratory of Hematology of Jiangxi Province, The Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huijun Chen
- The Key Laboratory of Hematology of Jiangxi Province, The Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jingyu Wang
- The Key Laboratory of Hematology of Jiangxi Province, The Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huaijun Tu
- The Department of Geratology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jian Li
- The Key Laboratory of Hematology of Jiangxi Province, The Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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6
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Atallah E, Saini L, Maegawa R, Rajput T, Corbin R, Viana R. Therapy for patients with chronic phase-chronic myeloid leukemia previously treated with ⩾2 tyrosine kinase inhibitors: a systematic literature review. Ther Adv Hematol 2023; 14:20406207221150305. [PMID: 38105770 PMCID: PMC10725100 DOI: 10.1177/20406207221150305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/22/2022] [Indexed: 12/19/2023] Open
Abstract
Background ATP-competitive tyrosine kinase inhibitors (TKIs) are the current standard of care for patients with chronic phase-chronic myeloid leukemia (CP-CML) in the first-line and second-line (2 L) setting. Treatment after 2 L is not clearly established. Objective The objective of this study was to summarize the available evidence to compare the efficacy and safety of interventions in the treatment of CP-CML patients who had received ⩾2 prior TKIs. Design A systematic literature review was performed. Data source and methods A systematic literature review (SLR) of studies published until May 2021, reporting clinical outcomes in adult patients with CP-CML who had received ⩾ 2 prior TKIs was performed. Studies were identified through the database searches via Ovid platform (Embase, MEDLINE Epub Ahead of Print, In-Process and Other Non-Indexed Citations, and Cochrane Central Register of Controlled Trials), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), bibliographic search of relevant reviews, and proceedings from the previous 3 years of the key conferences in the field of oncology. Results Our search identified 38 relevant studies. Among the identified studies of the current third-line treatments, the major molecular response (MMR) rate for ponatinib was 19.0-66.7%, 23.3-25.5% for asciminib, 19.2% for omacetaxine, and 13.2% for bosutinib at 6 months. The complete cytogenetic response (CCyR) rate was 21.4-64.8% for ponatinib, 38.7-40.8% for asciminib, 18-24.2% for bosutinib, and 16.1% for omacetaxine at 6 months. Conclusion The findings from current SLR demonstrated the lack of data for patients with CML treated with ⩾2 TKIs. TKIs such as asciminib, ponatinib, and bosutinib are valid options for those patients. Further research is needed to identify the best treatment option for patients with CML receiving later lines of therapy.
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Affiliation(s)
- Ehab Atallah
- Cancer Center – Froedtert Hospital, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | - Regina Corbin
- Novartis Services Inc, One Health Plaza, East Hanover, NJ 07936-1080, USA
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7
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Held N, Atallah EL. Real-world Management of CML: Outcomes and Treatment Patterns. Curr Hematol Malig Rep 2023; 18:167-175. [PMID: 37395944 DOI: 10.1007/s11899-023-00703-w] [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] [Accepted: 06/06/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE OF REVIEW Chronic myeloid leukemia (CML) is a disease that previously signified a poor prognosis, but treatment options and outcomes have improved over the last several decades. Despite this, challenges remain in optimal management in clinical practice, as the characteristics in trial populations differ from patients who are treated in a real-world setting. This review describes recent updates in real-world treatment patterns and outcomes in patients with CML. RECENT FINDINGS Several analyses describing real-world practice patterns show that tyrosine kinase inhibitors (TKIs) are the most commonly prescribed agents in multiple lines of therapy. First-generation (1G) and second-generation (2G) TKIs are the most commonly prescribed, even in the third line and beyond. Third-generation (3G) TKIs are typically utilized in patients with resistant disease who are younger with fewer comorbidities. Hematopoietic stem cell transplant (HSCT) is utilized significantly less, given other treatment options available. The goals of treatment with CML have shifted to quality of life, cost savings, and treatment-free response (TFR). Despite clear guidelines for attempting TFR, discontinuation practice patterns remain inconsistent. TKIs are the mainstay of CML treatment, including those in later lines of therapy. In real-world practice, several challenges still remain with regard to optimal management. Specifically, ideal sequencing of treatments, side effect profiles of tyrosine kinase inhibitors (TKIs), current role and timing of transplant, and adherence to recommendations for attempting to achieve a treatment-free response (TFR). A national registry could characterize these practice patterns in order to find ways to optimize care for CML patients.
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Affiliation(s)
- Nicole Held
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Ehab L Atallah
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.
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Purwar S, Fatima A, Bhattacharyya H, Simhachalam Kutikuppala LV, Cozma MA, Srichawla BS, Komer L, Nurani KM, Găman MA. Toxicity of targeted anticancer treatments on the liver in myeloproliferative neoplasms. World J Hepatol 2023; 15:1021-1032. [PMID: 37900211 PMCID: PMC10600697 DOI: 10.4254/wjh.v15.i9.1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/06/2023] [Accepted: 08/18/2023] [Indexed: 09/22/2023] Open
Abstract
The liver has a central role in metabolism, therefore, it is susceptible to harmful effects of ingested medications (drugs, herbs, and nutritional supplements). Drug-induced liver injury (DILI) comprises a range of unexpected reactions that occur after exposure to various classes of medication. Even though most cases consist of mild, temporary elevations in liver enzyme markers, DILI can also manifest as acute liver failure in some patients and can be associated with mortality. Herein, we briefly review available data on DILI induced by targeted anticancer agents in managing classical myeloproliferative neoplasms: Chronic myeloid leukemia, polycythemia vera, essential thrombocythemia, and myelofibrosis.
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Affiliation(s)
- Shubhrat Purwar
- Department of Internal Medicine, Grant Government Medical College, Mumbai 400008, Maharashtra, India
| | - Anam Fatima
- Department of Internal Medicine, Pandit Jawaharlal Nehru Memorial Medical College, Raipur 492001, Chhattisgarh, India
| | | | | | - Matei-Alexandru Cozma
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest 050474, Romania
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest 020125, Romania
| | - Bahadar Singh Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, United States
| | - Leah Komer
- Department of Psychiatry, University of Toronto, Toronto M5G 1V7, Ontario, Canada
| | | | - Mihnea-Alexandru Găman
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest 050474, Romania
- Department of Hematology, Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest 022328, Romania.
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Marx KR, Rausch CR, Lovell AR, Short NJ, Paul S, Jain N, Lee J, Savoy JM, Ravandi F, Jabbour E. Incidence of adverse effects in patients receiving ponatinib with concomitant azole antifungals. Leuk Lymphoma 2023; 64:79-86. [PMID: 36222579 DOI: 10.1080/10428194.2022.2131409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Ponatinib plus Hyper-CVAD yields a five-year overall survival of 73% in patients with Philadelphia-positive acute lymphoblastic leukemia. Ponatinib dose intensity is associated with increased incidence of adverse effects (AEs), including vascular events. Ponatinib combined with azole antifungals may further increase the risk of AEs due to increased ponatinib exposure. We reviewed 53 patients who received ponatinib with intensive (n = 39; 74%) or low-intensity chemotherapy (n = 14; 26%). Forty-eight patients (91%) received concomitant azole. Ponatinib was commonly initiated at 30 mg (n = 30; 57%) or 45 mg daily (n = 21; 40%). Twenty-six patients (49%) experienced at least one grade ≥3 AE possibly related to ponatinib; 19 (73%) were receiving a ponatinib dose equivalent ≥30mg and 58% >45mg. Eight patients (15%) experienced 10 vascular events, including 1 arterial event; 9 occurred on a ponatinib dose equivalent ≥30mg and 5 occurred while on an azole. Vascular events pose a clinical challenge with the risk potentially increasing with concomitant azoles.
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Affiliation(s)
- Kayleigh R Marx
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caitlin R Rausch
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexandra R Lovell
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shilpa Paul
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jenessa Lee
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Michael Savoy
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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10
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Breccia M, Olimpieri PP, Celant S, Olimpieri O, Pane F, Iurlo A, Summa V, Corradini P, Russo P. Management of chronic myeloid leukaemia patients treated with ponatinib in a real-life setting: A retrospective analysis from the monitoring registries of the Italian Medicines Agency (AIFA). Br J Haematol 2022; 198:965-973. [PMID: 35904979 DOI: 10.1111/bjh.18359] [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: 04/02/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022]
Abstract
Real-world data on daily practice management, treatment modifications and outcome of a large cohort of chronic myeloid leukaemia (CML) patients treated with ponatinib was performed through monitoring Registries of the Italian Medicines Agency (AIFA). Overall, 666 CML subjects were included in the ponatinib registry from February 2015 to December 2020 and were eligible for analysis: 515 in chronic phase (CP), 50 in accelerated phase (AP) and 101 in blast crisis (BC). Median age at baseline was 58.7 years with a predominance of male subjects (57.1%). The median time from diagnosis to start of ponatinib was 2.35 years: 259 (38.9%) subjects had received two previous lines of treatment, 260 (39.0%) three lines and 147 (22.1%) four or more lines. A molecular response [from major molecular response (MMR) to a score of ≤0.01% on the international reporting scale (IS)] was reported for 59% of patients out of 593 patients analysed. With a median follow-up of 14.4 months, 136 subjects (20.4%) required at least one dose reduction due to adverse events (AEs), whereas 309 patients (46.4%) required dose reduction in the absence of any evidence of side effects. Treatment discontinuation occurred in 261 patients (39%). This real-life analysis shows that dose reductions were made primarily as a precaution rather than due to the occurrence of adverse reactions.
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Affiliation(s)
- Massimo Breccia
- Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | | | | | | | - Fabrizio Pane
- Università degli Studi di Napoli Federico II, Naples, Italy
| | - Alessandra Iurlo
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Paolo Corradini
- Università degli Studi di Milano & Divisione Ematologia, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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Sacha T, Szczepanek E, Dumnicka P, Góra-Tybor J, Niesiobędzka-Krężel J, Prejzner W, Wasilewska E, Kłoczko J, Ciepłuch H, Makowska W, Patkowska E, Wasilewska J, Bober G, Kopera M, Wichary R, Kroll-Balcerzak R, Gromek T, Wach M, Rudkowska-Kazanowska A, Świniarska M, Paczkowska E, Biernat M, Joks M, Oller M, Kasza R, Kostyra A, Gil J, Grzybowska-Izydorczyk O. The Outcomes of Ponatinib Therapy in Patients With Chronic Myeloid Leukemia Resistant or Intolerant to Previous Tyrosine Kinase Inhibitors, Treated in Poland Within the Donation Program. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:405-415. [PMID: 34933827 DOI: 10.1016/j.clml.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Tyrosine kinase inhibitors (TKIs) have greatly improved the treatment outcome for most patients with chronic myeloid leukemia (CML). Ponatinib is a new pan-inhibitor of TK active in resistant CML. This study aimed to evaluate the efficacy and safety of ponatinib in patients suffering from CML. PATIENTS AND METHODS This multicenter, non-randomized, observational, retrospective study evaluated the efficacy and safety of ponatinib administered in adult CML patients in any disease phase, including those with a detected ABL T315I mutation, which were resistant or intolerant to previous-generation TKIs. The study comprised 43 patients benefiting from the ponatinib donation program who were treated in 16 Polish centers. RESULTS For patients who started treatment with ponatinib in chronic phase (CP) (n = 23) and in accelerated phase (AP) (n = 3) the median time on ponatinib was 19.5 months (range: 1.0-35.4), and 31.7 months (range: 31.0-34.1), respectively. All these patients were in CP after 1 month of treatment and at the end of observation - none of them progressed to AP or blastic phase (BP) during the study, meaning that progression-free survival was 100% at the end of observation (35.4 months). The estimated 2-year survival in this group of patients was 84%. For all 43 patients, median survival was not reached (lower quartile 6.3 months), and estimated 2-year survival was 60%. CONCLUSION Our analysis confirmed ponatinib efficacy in a significant proportion of patients heavily pre-treated with TKIs achieving durable responses in both CP and AP/BP CML groups.
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Affiliation(s)
- Tomasz Sacha
- Department of Hematology, Jagiellonian University Medical College, Krakow, Poland.
| | - Elżbieta Szczepanek
- Department of Hematology, Jagiellonian University Medical College, Krakow, Poland
| | - Paulina Dumnicka
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, Krakow, Poland
| | - Joanna Góra-Tybor
- Department of Hematology, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Joanna Niesiobędzka-Krężel
- Department of Hematology, Transplantation and Internal Medicine, University Clinical Center of the Medical University of Warsaw, Poland
| | - Witold Prejzner
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Ewa Wasilewska
- Department of Hematology, Medical University of Bialystok, Bialystok, Poland
| | - Janusz Kłoczko
- Department of Hematology, Medical University of Bialystok, Bialystok, Poland
| | - Hanna Ciepłuch
- Department of Hematology, Copernicus Regional Oncology Centre, Gdansk, Poland
| | - Wioletta Makowska
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Elżbieta Patkowska
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Joanna Wasilewska
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Grażyna Bober
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Małgorzata Kopera
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Ryszard Wichary
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Renata Kroll-Balcerzak
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Gromek
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Małgorzata Wach
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Anna Rudkowska-Kazanowska
- Department of Hematology and Cancer Prevention, School of Public Health in Bytom, Medical University of Silesia in Katowice, Bytom, Poland
| | - Magdalena Świniarska
- Department of Hematology and Transplantology, Pomeranian Medical University, Szczecin, Poland
| | - Edyta Paczkowska
- Department of General Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Monika Biernat
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Monika Joks
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Marta Oller
- Department of Hematology, Copernicus Regional Oncology Centre, Gdansk, Poland
| | - Renata Kasza
- Department of Hematology, Zamosc Hospital, Zamosc, Poland
| | | | - Justyna Gil
- Department of Hematooncology, Oncology Centre of the Podkarpackie Province, Brzozow, Poland
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12
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Lipton JH, Brümmendorf TH, Gambacorti-Passerini C, Garcia-Gutiérrez V, Deininger MW, Cortes JE. Long-term safety review of tyrosine kinase inhibitors in chronic myeloid leukemia - What to look for when treatment-free remission is not an option. Blood Rev 2022; 56:100968. [DOI: 10.1016/j.blre.2022.100968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 12/14/2022]
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Haddad FG, Issa GC, Jabbour E, Yilmaz M. Ponatinib for the treatment of adult patients with resistant or intolerant Chronic-Phase Chronic Myeloid Leukemia. Expert Opin Pharmacother 2022; 23:751-758. [PMID: 35412404 DOI: 10.1080/14656566.2022.2064742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patients with chronic myeloid leukemia in chronic phase (CP-CML) who are resistant or intolerant to second-generation tyrosine kinase inhibitors (TKIs) may benefit from treatment with a third-generation TKI, like ponatinib. AREAS COVERED In this review, the authors discuss the role of ponatinib, an oral pan-inhibitor of BCR-ABL1, with potent activity in heavily pretreated patients, including T315I mutation. In the long-term follow-up of the PACE trial, 60% of patients with prior TKIs exposure achieved a major cytogenetic response with ponatinib and 40% a major molecular response; 5-year overall survival was 73%. Cardiovascular adverse events represent the major toxicity associated with ponatinib. Adopting a dose-reduction approach appeared to be safe: starting with 45 or 30 mg and decreasing to 15 mg once BCR-ABL1/ABL1≤1% is achieved. In patients who are not candidates for ponatinib therapy, asciminib or other novel TKIs like HQP1351, represent alternative options. EXPERT OPINION In patients with CP-CML resistant or intolerant to second-generation TKIs, we favor using a third-generation TKI such as ponatinib. Although we initiate a donor search as soon as a patient fails a second-generation TKI, we still prefer treating patients with ponatinib and will only consider transplantation in the event of no response or disease progression.
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Affiliation(s)
- Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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14
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Impact of the treatment of chronic myeloid leukaemia by tyrosine-kinase inhibitors on sick leaves refund: a nationwide cohort study. Support Care Cancer 2022; 30:5431-5440. [PMID: 35304631 DOI: 10.1007/s00520-022-06968-w] [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: 07/31/2021] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The advent of chronic myeloid leukaemia (CML) tyrosine-kinase inhibitors (TKI) has led to new paradigms including occupational rehabilitation. OBJECTIVES This study aimed to characterize the impact of CML treatment on sick leaves within the 2 years following diagnosis in working-age patients. METHODS A cohort of all 18-60-year-old newly diagnosed CML patients initiating a TKI between January 1st 2011 and December 31st 2014 in France was identified in the French National Healthcare database (Système National des Données de Santé [SNDS]). Patients with a sick leave identified in the 24 months after TKI initiation were compared with sex and initiation date matched controls in a nested case-control design. Factors associated with sick leaves were identified through a conditional logistic regression model, providing adjusted odds-ratio (OR) with their 95% confidence interval (CI). RESULTS Among 646 18-60-year-old patients, 268 were prescribed at least one sick leave in the study period, with 176 (27.2%) having their first sick leave prescribed after TKI initiation. The median number of sick days over the 2-years period was 115 per patient (interquartile range 25.5-384.5). In the nested case-control study (176 cases and 176 matched controls), sick leaves were more likely observed with second generation TKI (OR 4.11 [1.80-9.38]), whereas they were less likely observed in case if social deprivation (OR 0.07 [0.02-0.28]. CONCLUSION More than 25% of working-age CML patients had at least one sick leave within 2 years of TKI initiation, with a higher impact of second generation TKI, and with a median duration of 115 days.
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15
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Januzzi JL, Garasic JM, Kasner SE, McDonald V, Petrie MC, Seltzer J, Mauro M, Croce K, Berman E, Deininger M, Hochhaus A, Pinilla-Ibarz J, Nicolini F, Kim DW, DeAngelo DJ, Kantarjian H, Xu J, Hall T, Srivastava S, Naranjo D, Cortes J. Retrospective analysis of arterial occlusive events in the PACE trial by an independent adjudication committee. J Hematol Oncol 2022; 15:1. [PMID: 34991679 PMCID: PMC8734305 DOI: 10.1186/s13045-021-01221-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/18/2021] [Indexed: 11/29/2022] Open
Abstract
Background The phase 2 PACE (Ponatinib Ph+ ALL and CML Evaluation) trial of ponatinib showed robust long-term benefit in relapsed Philadelphia chromosome-positive (Ph+) leukemia; arterial occlusive events (AOEs) occurred in ≥ 25% of patients based on investigator reporting. However, AOE rates vary depending on the definitions and reporting approach used. Methods To better understand clinically relevant AOEs with ponatinib, an independent cardiovascular adjudication committee reviewed 5-year AOE data from the PACE trial according to a charter-defined process and standardized event definitions. Results A total of 449 patients with chronic myeloid leukemia (CML) or Ph+ acute lymphoblastic leukemia (ALL) received ponatinib (median age 59 y; 47% female; 93% ≥ 2 prior tyrosine kinase inhibitors (TKIs); median follow-up, 37.3 months). The adjudicated AOE rate (17%) was lower than the non-adjudicated rate (i.e., rate before adjudication; 25%). The only adjudicated AOE in > 2% of patients was peripheral arterial occlusive disease (4%). Exposure-adjusted incidence of newly occurring adjudicated AOEs decreased over time. Patients with multiple baseline cardiovascular risk factors had higher adjudicated AOE rates than those without risk factors.
Conclusions This independent adjudication study identified lower AOE rates than previously reported, suggesting earlier overestimation that may inaccurately reflect AOE risk with ponatinib. This trial was registered under ClinicalTrials.gov identifier NCT01207440 on September 23, 2010 (https://clinicaltrials.gov/ct2/show/NCT01207440).
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Affiliation(s)
- James L Januzzi
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - Joseph M Garasic
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | | | | | | | | | - Michael Mauro
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin Croce
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellin Berman
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Deininger
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, UT, USA
| | | | | | | | - Dong-Wook Kim
- Catholic Hematology Hospital, Seoul St. Mary's Hospital, Leukemia Research Institute, The Catholic University of Korea, Seoul, South Korea
| | | | - Hagop Kantarjian
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Xu
- Millennium Pharmaceuticals, Inc., A Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Tracey Hall
- Millennium Pharmaceuticals, Inc., A Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Shouryadeep Srivastava
- Millennium Pharmaceuticals, Inc., A Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Daniel Naranjo
- Millennium Pharmaceuticals, Inc., A Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
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16
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Masouridi-Levrat S, Olavarria E, Iacobelli S, Aljurf M, Morozova E, Niittyvuopio R, Sengeloev H, Reményi P, Helbig G, Browne P, Ganser A, Nagler A, Snowden JA, Robin M, Passweg J, Van Gorkom G, Wallet HL, Hoek J, Blok HJ, De Witte T, Kroeger N, Hayden P, Chalandon Y, Agha IY. Outcomes and toxicity of allogeneic hematopoietic cell transplantation in chronic myeloid leukemia patients previously treated with second-generation tyrosine kinase inhibitors: a prospective non-interventional study from the Chronic Malignancy Working Party of the EBMT. Bone Marrow Transplant 2022; 57:23-30. [PMID: 34599284 PMCID: PMC8732279 DOI: 10.1038/s41409-021-01472-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/17/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) remains a treatment option for patients with chronic myeloid leukemia (CML) who fail to respond to tyrosine kinase inhibitors (TKIs). While imatinib seems to have no adverse impact on outcomes after transplant, little is known on the effects of prior use of second-generation TKI (2GTKI). We present the results of a prospective non-interventional study performed by the EBMT on 383 consecutive CML patients previously treated with dasatinib or nilotinib undergoing allo-HCT from 2009 to 2013. The median age was 45 years (18-68). Disease status at transplant was CP1 in 139 patients (38%), AP or >CP1 in 163 (45%), and BC in 59 (16%). The choice of 2GTKI was: 40% dasatinib, 17% nilotinib, and 43% a sequential treatment of dasatinib and nilotinib with or without bosutinib/ponatinib. With a median follow-up of 37 months (1-77), 8% of patients developed either primary or secondary graft failure, 34% acute and 60% chronic GvHD. There were no differences in post-transplant complications between the three different 2GTKI subgroups. Non-relapse mortality was 18% and 24% at 12 months and at 5 years, respectively. Relapse incidence was 36%, overall survival 56% and relapse-free survival 40% at 5 years. No differences in post-transplant outcomes were found between the three different 2GTKI subgroups. This prospective study demonstrates the feasibility of allo-HCT in patients previously treated with 2GTKI with a post-transplant complications rate comparable to that of TKI-naive or imatinib-treated patients.
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Affiliation(s)
- Stavroula Masouridi-Levrat
- Hematology Division and Faculty of Medicine, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland.
| | | | | | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Elena Morozova
- First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russia
| | | | | | | | | | | | | | - Arnon Nagler
- Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | | | | | | | - Gwendolyn Van Gorkom
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | | | - Theo De Witte
- Nijmegen Medical Centre, Radboud University, Nijmegen, Netherlands
| | - Nicolaus Kroeger
- Department of Stem Cell Transplantation, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Yves Chalandon
- Hematology Division and Faculty of Medicine, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
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Mulas O, Caocci G, Mola B, La Nasa G. Arterial Hypertension and Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:674748. [PMID: 34630076 PMCID: PMC8493251 DOI: 10.3389/fphar.2021.674748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/03/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Off-target effects in chronic myeloid leukemia (CML) patients treated with tyrosine kinase inhibitors (TKIs) are associated with cardiovascular toxicity. Hypertension represents an important cardiovascular complication and, if not appropriately managed, can contribute to developing thrombotic events. Third-generation TKI ponatinib is associated with hypertension development, and its use is more restricted than in the past. Few data are reported for second-generation TKI, nilotinib, dasatinib, and bosutinib. The aim of this article was to evaluate with a systematic review and meta-analysis the real incidence of hypertension in CML patients treated with second- or third-generation TKI. Methods: The PubMed database, Web of Science, Scopus, and ClinicalTrials.gov were systematically searched for studies published between January 1, 2000, and January 30, 2021; the following terms were entered in the database queries: Cardiovascular, Chronic Myeloid Leukemia, CML, Tyrosine kinases inhibitor, TKI, and Hypertension. The study was carried out according to the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) statement. Results: A pooled analysis of hypertension incidence was 10% for all new-generation TKI, with an even higher prevalence with ponatinib (17%). The comparison with the first-generation imatinib confirmed that nilotinib was associated with a significantly increased risk of hypertension (RR 2; 95% CI; 1.39-2.88, I2=0%, z=3.73, p=0.0002). The greatest risk was found with ponatinib (RR 9.21; 95% CI; 2.86-29.66, z=3.72, p=0.0002). Conclusion: Hypertension is a common cardiovascular complication in CML patients treated with second- or third-generation TKI.
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Affiliation(s)
- Olga Mulas
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giovanni Caocci
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Brunella Mola
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giorgio La Nasa
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Side-effects profile and outcomes of ponatinib in the treatment of chronic myeloid leukemia. Blood Adv 2021; 4:530-538. [PMID: 32045474 DOI: 10.1182/bloodadvances.2019000268] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 01/06/2020] [Indexed: 12/20/2022] Open
Abstract
Ponatinib is associated with cardiovascular adverse events (CAEs), and its frequency in the real world is limited. In this retrospective study, we examined the survival outcomes and associated toxicities in 78 consecutive ponatinib-treated patients with chronic myeloid leukemia (CML) at the Moffitt Cancer Center from January 2011 through December 2017. The most common non-CAE was thrombocytopenia (39.7%), occurring in a dose-dependent fashion. Eighteen patients (23.1%) experienced some form of CAE, with the most common being arrhythmia (9%) and hypertension (7.7%), whereas 3 patients experienced myocardial infarction (3.8%). Before 2014, most patients were started on ponatinib 45 mg daily. There was an inverse correlation between cardio-oncology referral and the number of CAEs (P = .0440); however, a lower ponatinib starting dose, more frequent dose reduction, and increased cardio-oncology referral all were likely to have contributed to the observed decrease in CAEs after 2014. The response rate and 5-year overall survival (OS) were higher than those observed in the Ponatinib Ph+ ALL and CML Evaluation (PACE) trial (major molecular response, 58.7% vs 40% and OS, 76% vs 73%; median follow-up of 32.5 months). Ponatinib-treated patients with chronic phase-CML did not show a significant improvement with allogeneic stem cell transplantation, whereas those with accelerated phase/blast phase-CML had a much better outcome (median OS of 32.9 months vs 9.2 months; P = .01). These results demonstrate that ponatinib is highly effective. Dose adjustments and increased awareness of the cardiotoxicities associated with ponatinib may help maximize its benefits.
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Devos T, Havelange V, Theunissen K, Meers S, Benghiat FS, Gadisseur A, Vanstraelen G, Vellemans H, Bailly B, Granacher N, Lewalle P, De Becker A, Van Eygen K, Janssen M, Triffet A, Vrelust I, Deeren D, Mazure D, Bekaert J, Beck M, Selleslag D. Clinical outcomes in patients with Philadelphia chromosome-positive leukemia treated with ponatinib in routine clinical practice-data from a Belgian registry. Ann Hematol 2021; 100:1723-1732. [PMID: 33942128 PMCID: PMC8195783 DOI: 10.1007/s00277-021-04507-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 04/03/2021] [Indexed: 12/04/2022]
Abstract
Data on clinical use of ponatinib are limited. This prospective registry aimed to evaluate outcomes of ponatinib treatment in routine practice over 3 years (2016–2019) in Belgium (NCT03678454). Patients with chronic myeloid leukemia (CML) or Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) were treated with ponatinib per current label. Fifty patients (33 CML and 17 Ph+ ALL) were enrolled. Fifty-five percent of CML and 29% of Ph+ ALL patients had received ≥3 prior tyrosine kinase inhibitors (TKIs). Reasons for starting ponatinib were intolerance (40%), relapse or refractoriness (28%) to previous TKIs, progression (16%), or T315I mutation (16%). Median follow-up was 15 months for CML and 4.5 months for Ph+ ALL patients. Best response was a major molecular response in 58% of CML and 41% of Ph+ ALL patients. Of 20 patients who started ponatinib due to intolerance to previous TKIs, 9 (64%) CML and 4 (67%) Ph+ ALL achieved a major molecular response. Three-year estimates of overall survival were 85.3% and 85.6%, respectively, in CML and Ph+ ALL patients; estimated progression-free survival was 81.6% and 48.9%. Adverse reactions were reported in 34 patients (68%); rash (26%) and dry skin (10%) were most common. Reported cardiovascular adverse reactions included vascular stenosis (3), arterial hypertension (2), chest pain (1), palpitations (1), and vascular occlusion (1). This Belgian registry confirms results from the PACE clinical trial and supports routine ponatinib use in CML and Ph+ ALL patients who are resistant or intolerant to previous TKIs or with the T315I mutation.
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Affiliation(s)
- Timothy Devos
- Department of Hematology, University Hospitals Leuven and Department of Microbiology and Immunology, Laboratory of Molecular Immunology (Rega Institute), KU Leuven, Campus Gasthuisberg, Herestraat 49, B-3000, Leuven, Belgium.
| | | | | | - Stef Meers
- Algemeen Ziekenhuis Klina, Brasschaat, Belgium
| | | | | | | | | | | | - Nikki Granacher
- Ziekenhuis Netwerk Antwerpen Stuivenberg, Antwerpen, Belgium
| | - Philippe Lewalle
- Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, Belgium
| | | | | | | | - Agnes Triffet
- Centre Hospitalier Universitaire Charleroi Vésale, Charleroi, Belgium
| | - Inge Vrelust
- Algemeen Ziekenhuis Sint-Elisabeth, Turnhout, Belgium
| | | | | | - Julie Bekaert
- Incyte Biosciences International sàrl, Morges, Switzerland
| | - Michael Beck
- Incyte Biosciences Benelux B.V., Amsterdam, The Netherlands
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20
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Abstract
While the need for complete eradication of leukemic stem cells (LSCs) in chronic myeloid leukemia may be controversial, it is agreed that remaining LSCs are the cause of relapse and disease progression. Current efforts are focused on the understanding of the persistence of immunophenotypically defined LSCs, which feature abnormalities in signaling pathways relating to autophagy, metabolism, epigenetics, and others and are influenced by leukemia cell-extrinsic factors such as the immune and bone marrow microenvironments. In sum, these elements modulate response and resistance to therapies and the clinical condition of treatment-free remission (TFR), the newly established goal in CML treatment, once the patient has achieved a durable molecular remission after treatment with tyrosine kinase inhibitors. Novel combination therapies based on these identified vulnerabilities of LSCs, aimed at the induction or maintenance of TFR, are being developed, while other research is directed at the elucidation of factors mediating progression to blast crisis.
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Affiliation(s)
- Rahul Kumar
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, 60596 Frankfurt, Germany
| | - Daniela S Krause
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, 60596 Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- Faculty of Medicine, Johann Wolfgang Goethe University, Frankfurt, Germany
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21
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Castagnetti F, Pane F, Rosti G, Saglio G, Breccia M. Dosing Strategies for Improving the Risk-Benefit Profile of Ponatinib in Patients With Chronic Myeloid Leukemia in Chronic Phase. Front Oncol 2021; 11:642005. [PMID: 33796468 PMCID: PMC8009177 DOI: 10.3389/fonc.2021.642005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/29/2021] [Indexed: 01/01/2023] Open
Abstract
The treatment of chronic myeloid leukemia (CML) has been advanced by the development of small-molecule tyrosine kinase inhibitors (TKIs), which target the fusion protein BCR-ABL1 expressed by the Philadelphia chromosome. Ponatinib is a 3rd generation TKI that binds BCR-ABL1 with high affinity and inhibits most BCR-ABL1 mutants, including the T315I mutation. The approved starting dose of ponatinib is 45 mg once daily (full dose), however, the need for a full dose, especially in patients with dose adjustments due to tolerability problems, remains undemonstrated. Lower starting doses of ponatinib (30 mg or 15 mg once daily) for patients “with lesser degrees of resistance or multiple intolerances, especially those with an increased cardiovascular risk profile” has been recommended by the 2020 European LeukemiaNet. However, the available literature and guidance on the use of ponatinib at low dosage are limited. The objective of this paper is to describe how we select ponatinib dosage for CML patients in chronic phase in our clinical practice based on the available evidence and our clinical experience. We propose dosing regimens for the optimal starting dose for six generic cases of CML patients in chronic phase eligible for the switch to ponatinib and provide an algorithm to guide ponatinib dosing during treatment.
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Affiliation(s)
- Fausto Castagnetti
- Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Fabrizio Pane
- Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli Federico II, Napoli, Italy
| | - Gianantonio Rosti
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Giuseppe Saglio
- Division of Hematology & Internal Medicine, Department of Clinical & Biological Sciences of the University of Turin, 'San Luigi Gonzaga' University Hospital, Orbassano, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
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22
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Sauvey C, Ehrenkaufer G, Shi D, Debnath A, Abagyan R. Antineoplastic kinase inhibitors: A new class of potent anti-amoebic compounds. PLoS Negl Trop Dis 2021; 15:e0008425. [PMID: 33556060 PMCID: PMC7895358 DOI: 10.1371/journal.pntd.0008425] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 02/19/2021] [Accepted: 12/21/2020] [Indexed: 12/17/2022] Open
Abstract
Entamoeba histolytica is a protozoan parasite which infects approximately 50 million people worldwide, resulting in an estimated 70,000 deaths every year. Since the 1960s E. histolytica infection has been successfully treated with metronidazole. However, drawbacks to metronidazole therapy exist, including adverse effects, a long treatment course, and the need for an additional drug to prevent cyst-mediated transmission. E. histolytica possesses a kinome with approximately 300–400 members, some of which have been previously studied as potential targets for the development of amoebicidal drug candidates. However, while these efforts have uncovered novel potent inhibitors of E. histolytica kinases, none have resulted in approved drugs. In this study we took the alternative approach of testing a set of twelve previously FDA-approved antineoplastic kinase inhibitors against E. histolytica trophozoites in vitro. This resulted in the identification of dasatinib, bosutinib, and ibrutinib as amoebicidal agents at low-micromolar concentrations. Next, we utilized a recently developed computational tool to identify twelve additional drugs with human protein target profiles similar to the three initial hits. Testing of these additional twelve drugs led to the identification of ponatinib, neratinib, and olmutinib were identified as highly potent, with EC50 values in the sub-micromolar range. All of these six drugs were found to kill E. histolytica trophozoites as rapidly as metronidazole. Furthermore, ibrutinib was found to kill the transmissible cyst stage of the model organism E. invadens. Ibrutinib thus possesses both amoebicidal and cysticidal properties, in contrast to all drugs used in the current therapeutic strategy. These findings together reveal antineoplastic kinase inhibitors as a highly promising class of potent drugs against this widespread and devastating disease. Every year, nearly a hundred thousand people worldwide die from infection by the intestinal parasite Entamoeba histolytica, despite the widespread availability of metronidazole as a treatment. Here we report that six anticancer drugs of the kinase inhibitor class possess potent anti-amoebic properties, with one of them killing both actively dividing parasite and its transmissible cysts. These anticancer kinase inhibitors, including the dual-purpose drug with both amoebicidal and cysticidal activities may be used to treat amoebiasis, especially in cancer patients or in life-threatening brain- and liver-infecting forms of the disease.
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Affiliation(s)
- Conall Sauvey
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School for Pharmacy and Pharmaceutical Sciences, University of California—San Diego, La Jolla, California, United States of America
- * E-mail: (CS); (RA)
| | - Gretchen Ehrenkaufer
- Division of Infectious Diseases, Department of Internal Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Da Shi
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School for Pharmacy and Pharmaceutical Sciences, University of California—San Diego, La Jolla, California, United States of America
| | - Anjan Debnath
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School for Pharmacy and Pharmaceutical Sciences, University of California—San Diego, La Jolla, California, United States of America
| | - Ruben Abagyan
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School for Pharmacy and Pharmaceutical Sciences, University of California—San Diego, La Jolla, California, United States of America
- * E-mail: (CS); (RA)
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23
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Iurlo A, Cattaneo D, Malato A, Accurso V, Annunziata M, Gozzini A, Scortechini AR, Bucelli C, Scalzulli E, Attolico I, Maggi A, Martino B, Caocci G, Abruzzese E, Pregno P, Luciano L, Breccia M. Low-dose ponatinib is a good option in chronic myeloid leukemia patients intolerant to previous TKIs. Am J Hematol 2020; 95:E260-E263. [PMID: 32557788 DOI: 10.1002/ajh.25908] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/08/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022]
MESH Headings
- Adolescent
- Adult
- Child
- Child, Preschool
- Female
- Follow-Up Studies
- Humans
- Imidazoles/administration & dosage
- Imidazoles/adverse effects
- Infant
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Male
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/adverse effects
- Pyridazines/administration & dosage
- Pyridazines/adverse effects
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Affiliation(s)
- Alessandra Iurlo
- Division of Hematology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Cattaneo
- Division of Hematology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Malato
- Division of Hematology, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Vincenzo Accurso
- Division of Hematology, AOU Policlinico "P. Giaccone", University of Palermo, Palermo, Italy
| | | | | | - Anna Rita Scortechini
- Division of Hematology, Department of Molecular and Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Cristina Bucelli
- Division of Hematology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emilia Scalzulli
- Division of Hematology, Department of Precision and Translational Medicine, Policlinico Umberto 1, Sapienza University, Rome, Italy
| | - Imma Attolico
- Division of Hematology and Transplant Unit, Policlinico of Bari, Bari, Italy
| | | | - Bruno Martino
- Division of Hematology, Azienda Ospedaliera "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Giovanni Caocci
- Hematology Unit, Department of Medical Sciences and Public Health, Businco Hospital, University of Cagliari, Cagliari, Italy
| | | | - Patrizia Pregno
- Division of Hematology, AOU Città della Salute e della Scienza, Turin, Italy
| | - Luigiana Luciano
- Division of Hematology, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Massimo Breccia
- Division of Hematology, Department of Precision and Translational Medicine, Policlinico Umberto 1, Sapienza University, Rome, Italy
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24
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Zeng P, Schmaier A. Ponatinib and other CML Tyrosine Kinase Inhibitors in Thrombosis. Int J Mol Sci 2020; 21:ijms21186556. [PMID: 32911643 PMCID: PMC7555546 DOI: 10.3390/ijms21186556] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/25/2020] [Accepted: 09/03/2020] [Indexed: 01/05/2023] Open
Abstract
Abl1 kinase has important biological roles. The Bcr-Abl1 fusion protein creates undesired kinase activity and is pathogenic in 95% of chronic myeloid leukemia (CML) and 30% of acute lymphoblastic leukemia (ALL) patients. Targeted therapies to these diseases are tyrosine kinase inhibitors. The extent of a tyrosine kinase inhibitor’s targets determines the degree of biologic effects of the agent that may influence the well-being of the patient. This fact is especially true with tyrosine kinase inhibitor effects on the cardiovascular system. Thirty-one percent of ponatinib-treated patients, the tyrosine kinase inhibitor with the broadest inhibitory spectrum, have thrombosis associated with its use. Recent experimental investigations have indicated the mechanisms of ponatinib-associated thrombosis. Further, an antidote to ponatinib is in development by re-purposing an FDA-approved medication.
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Affiliation(s)
- Peng Zeng
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Alvin Schmaier
- Departments of Medicine and Pathology, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
- Correspondence: ; Tel.: +1-216-368-0796; Fax: +1-216-368-3014
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25
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Current Treatment Options for Chronic Myeloid Leukemia Patients Failing Second-Generation Tyrosine Kinase Inhibitors. J Clin Med 2020; 9:jcm9072251. [PMID: 32679880 PMCID: PMC7408792 DOI: 10.3390/jcm9072251] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/23/2022] Open
Abstract
Despite the excellent overall survival (OS) of patients with chronic myeloid leukemia (CML), a significant proportion will not achieve optimal response to imatinib or second-generation tyrosine kinase inhibitors (2GTKI). For patients with inadequate response to 2GTKIs, alternative 2GTKIs or ponatinib are widely available treatment options in daily clinical practice. Treatment decisions should be guided by correct identification of the cause of treatment failure and accurate distinction between resistant from intolerant or nonadherence patients. This review aims to provide practical advice on how to select the best treatment option in each clinical scenario.
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26
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Ponatinib in childhood Philadelphia chromosome-positive leukaemias: an international registry of childhood chronic myeloid leukaemia study. Eur J Cancer 2020; 136:107-112. [PMID: 32668374 DOI: 10.1016/j.ejca.2020.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/16/2020] [Accepted: 05/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ponatinib is effective in adults with Philadelphia chromosome-positive (Ph+) leukaemias, but scant data are available regarding the use of this tyrosine kinase inhibitor in children. AIMS The aim of this study isto describe the tolerance and efficacy of compassionate use of ponatinib in a paediatric cohort of patients with Ph+ leukaemias. METHODS Data from 11 children with chronic myeloid leukaemia (CML) registered to the international registry of childhood chronic myeloid leukaemia and from 3 children with Ph+ acute lymphoblastic leukaemia (Ph+ ALL) treated with ponatinib were collected retrospectively. RESULTS In 11 girls and 3 boys (median age 14 years), ponatinib was used as a second- to eighth-line treatment. Ponatinib was administered as single therapy (9 patients) or in combination with chemotherapy (8 patients). The status of the disease when ponatinib was started was as follows: CML in advanced phases (n = 8), CML in chronic phase without achievement of molecular response (n = 2) or presence of T315I mutation (n = 1) and Ph + ALL in molecular (n = 1) or marrow (n = 2) relapses. The median dose administered was 21.4 mg/m2 and median duration of ponatinib was 2.5 months. Ponatinib alone or in combination with chemotherapy administered on 16 occasions led to achievement of major molecular response in 50% of cases. Ponatinib was used as a bridge to transplant in 4 cases. Among the 9 patients treated with ponatinib alone, toxicity grade III-IV (2 patients) was exclusively haematologic. No vascular events related to ponatinib were observed. CONCLUSION Ponatinib may be a reasonable additional treatment option for children with Ph+ leukaemias who have failed several lines of therapy.
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27
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Tavitian S, Uzunov M, Bérard E, Bouscary D, Thomas X, Raffoux E, Leguay T, Gallego Hernanz MP, Berceanu A, Leprêtre S, Hicheri Y, Chevallier P, Bertoli S, Lhéritier V, Dombret H, Huguet F. Ponatinib-based therapy in adults with relapsed or refractory Philadelphia chromosome-positive acute lymphoblastic leukemia: results of the real-life OPAL study. Leuk Lymphoma 2020; 61:2161-2167. [DOI: 10.1080/10428194.2020.1762876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Suzanne Tavitian
- Department of Hematology, Institut Universitaire du Cancer Toulouse-Oncopole, CHU de Toulouse, Toulouse, France
| | - Madalina Uzunov
- Department of Hematology, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Emilie Bérard
- CHU de Toulouse, UMR 1027, INSERM-Université Toulouse III, Toulouse, France
| | | | - Xavier Thomas
- Department of Hematology, CHU de Lyon Sud, Pierre-Bénite, France
| | - Emmanuel Raffoux
- AP-HP, Hopital Saint-Louis, Service Hematologie Adulte, Paris, France
| | - Thibaut Leguay
- Service d'hématologie clinique et thérapie cellulaire, Hôpital du Haut-Lévèque, CHU de Bordeaux, Bordeaux, France
| | | | - Ana Berceanu
- Department of Hematology, CHU Besancon, Besancon, France
| | | | | | | | - Sarah Bertoli
- Department of Hematology, Institut Universitaire du Cancer Toulouse-Oncopole, CHU de Toulouse, Toulouse, France
| | - Véronique Lhéritier
- Group for Research on Adult Acute Lymphoblastic Leukemia (GRAALL), Lyon, France
| | - Hervé Dombret
- Hospital Saint-Louis, Hématologie Adulte, Paris, France
| | - Françoise Huguet
- Department of Hematology, Institut Universitaire du Cancer Toulouse-Oncopole, CHU de Toulouse, Toulouse, France
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28
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Cardiovascular Toxicity of Tyrosine Kinase Inhibitors Used in Chronic Myeloid Leukemia: An Analysis of the FDA Adverse Event Reporting System Database (FAERS). Cancers (Basel) 2020; 12:cancers12040826. [PMID: 32235443 PMCID: PMC7226142 DOI: 10.3390/cancers12040826] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 12/14/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs), the treatment of choice for chronic myeloid leukemia (CML), can be associated to cardiovascular (CV) adverse events (AEs). A case/non-case study was performed using AE reports registered in the Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database to compare the risk of CV event reports related to TKIs indicated in the management of chronic myeloid leukemia (CML). Disproportionality of CV event-related TKIs was computed using the Reporting Odds Ratio (ROR) as a measure of potential risk increase. Nilotinib accounts for more than half of reported cases related to TKIs. Signal of Disproportionate Reporting (SDR) was found for cardiac failure, ischemic heart disease, cardiac arrhythmias, torsade de pointes/QT prolongation, hypertension, and pulmonary hypertension. Dasatinib and bosutinib were related to the highest disproportionality for cardiac failure. Nilotinib was associated with the highest SDR for ischemic heart disease, torsade de pointes/QT prolongation and cardiac arrhythmias. Only ponatinib was related to an SDR for hypertension, while dasatinib and imatinib were related to pulmonary hypertension. In the context of CML, TKIs have different safety profiles related to CV events, among which nilotinib seems particularly related to. These results claim for a revision of its CV safety profile mainly for the risk of torsade de pointes/QT prolongation.
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29
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Luciano L, Annunziata M, Attolico I, Di Raimondo F, Maggi A, Malato A, Martino B, Palmieri F, Pane F, Sgherza N, Specchia G. The multi-tyrosine kinase inhibitor ponatinib for chronic myeloid leukemia: Real-world data. Eur J Haematol 2020; 105:3-15. [PMID: 32145037 DOI: 10.1111/ejh.13408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/19/2022]
Abstract
Development of the highly selective targeted tyrosine kinase inhibitors (TKIs) has expanded the therapeutic options for chronic myeloid leukemia (CML). Patients undergoing TKI therapy should be closely monitored to ensure that the best therapeutic response and quality of life are achieved, and to control suboptimal responses and adverse events. Despite the high rate of response using current first-line TKIs, treatment failure may still occur, and resistance is considered a challenge in the treatment of patients with CML. The third-generation TKI, ponatinib, is a potent orally bioavailable pan BCR-ABL inhibitor that inhibits both wild-type and mutant BCR-ABL1 kinase, including the "gatekeeper" T315I mutation, which is resistant to all other currently available TKIs. This paper reviews the effectiveness, feasibility, and safety of ponatinib in the real-life clinical management of CML. Potential prognostic factors in identifying patients most likely to benefit from ponatinib treatment will be discussed, and case presentations illustrating situations encountered in real-life clinical practice are described. Ponatinib is effective in patients who have received prior TKIs in clinical studies as well as under real-life conditions. Nevertheless, the risk/benefit balance must be evaluated for each patient, particularly considering disease state, mutational status, treatment line, intolerance/resistance to prior TKIs, age, frailty, and specific comorbidities.
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Affiliation(s)
- Luigia Luciano
- Hematology - Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | | | | | - Francesco Di Raimondo
- Division of Hematology, AOU Policlinico-OVE, Department of Surgery and Medical Specialties, University of Catania, Catania, Italy
| | | | - Alessandra Malato
- UOC di Ematologia con UTMO, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Bruno Martino
- Azienda Ospedaliera "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Fausto Palmieri
- Department of Hematology, AORN, "S.G. Moscati", Avellino, Italy
| | - Fabrizio Pane
- Hematology - Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
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30
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He JB, Zhang X, Guo ZW, Liu MM, Xu N, Huang F, Fan ZP, Xuan L, Deng L, Lin SH, Xu J, Sun J, Liu QF. Ponatinib therapy in recurrent Philadelphia chromosome-positive central nervous system leukemia with T315I mutation after Allo-HSCT. Int J Cancer 2019; 147:1071-1077. [PMID: 31785158 DOI: 10.1002/ijc.32817] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 11/12/2019] [Accepted: 11/20/2019] [Indexed: 11/06/2022]
Abstract
Central nervous system leukemia (CNSL) relapse is relatively common among Philadelphia chromosome-positive (Ph+) leukemia patients who undergo allogeneic hematopoietic stem cell transplantation (allo-HSCT). The prognosis of patients is dismal for those with a BCR-ABL T315I mutation, which is resistant to TKIs including second-generation drugs. We assessed ponatinib for nine patients with recurrent Ph+ CNSL and a T315I mutation after allo-HSCT, including five patients with Ph+ acute lymphoblastic leukemia and four with chronic myelogenous leukemia. Five patients experienced isolated CNSL relapse, and four experienced CNSL with hematologic relapse. All patients received ponatinib combined with intrathecal chemotherapy, and four patients with hematologic relapse received systemic chemotherapy and/or donor lymphocyte infusion. All patients achieved a deep molecular response and central nervous system remission (CNSR) at a median time of 1.5 (range: 0.7-3) months after ponatinib treatment. Two patients experienced a second CNSL relapse due to ponatinib reduction, but they achieved CNSR again after an increase to the standard dosage. Six patients developed graft versus host disease. By April 1, 2019, eight patients were alive, and one died of pneumonia. The median time of survival after the first CNSL relapse posttransplantation was 18 (range: 11.2-48.5) months. Our data from a small number of samples suggests that ponatinib is effective for recurrent Ph+ CNSL patients with a BCR-ABL T315I mutation after allo-HSCT and warrants broader clinical evaluation.
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Affiliation(s)
- Jia-Bao He
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xin Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zi-Wen Guo
- Department of Hematology, Zhongshan City People's Hospital, Zhongshan, China
| | - Miao-Miao Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Ping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lan Deng
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shu-Hua Lin
- Department of Hematology, Zhongshan City People's Hospital, Zhongshan, China
| | - Jun Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qi-Fa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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31
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Saussele S, Haverkamp W, Lang F, Koschmieder S, Kiani A, Jentsch-Ullrich K, Stegelmann F, Pfeifer H, La Rosée P, Goekbuget N, Rieger C, Waller CF, Franke GN, le Coutre P, Kirchmair R, Junghanss C. Ponatinib in the Treatment of Chronic Myeloid Leukemia and Philadelphia Chromosome-Positive Acute Leukemia: Recommendations of a German Expert Consensus Panel with Focus on Cardiovascular Management. Acta Haematol 2019; 143:217-231. [PMID: 31590170 DOI: 10.1159/000501927] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 12/14/2022]
Abstract
Treatment of chronic myeloid leukemia (CML) and Philadelphia chromosome-positive acute leukemia (Ph+ ALL) has been revolutionized with the advent of tyrosine kinase inhibitors (TKIs). Most patients with CML achieve long-term survival similar to individuals without CML due to treatment with TKIs not only in frontline but also in further lines of therapy. The third-generation TKI ponatinib has demonstrated efficacy in patients with refractory CML and Ph+ ALL. Ponatinib is currently the most potent TKI in this setting demonstrating activity against T315I mutant clones. However, ponatinib's safety data revealed a dose-dependent, increased risk of serious cardiovascular (CV) events. Guidance is needed to evaluate the benefit-risk profile of TKIs, such as ponatinib, and safety measures to prevent treatment-associated CV events. An expert panel of German hematologists and cardiologists summarize current evidence regarding ponatinib's efficacy and CV safety profile. We propose CV management strategies for patients who are candidates for ponatinib.
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MESH Headings
- Adult
- Aged
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Cardiovascular Diseases/chemically induced
- Cardiovascular Diseases/physiopathology
- Cardiovascular Diseases/prevention & control
- Clinical Trials as Topic
- Dose-Response Relationship, Drug
- Drug Resistance, Neoplasm
- Female
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Humans
- Hyperglycemia/complications
- Hyperglycemia/drug therapy
- Hyperlipidemias/complications
- Hyperlipidemias/drug therapy
- Hypertension/complications
- Hypertension/drug therapy
- Imidazoles/administration & dosage
- Imidazoles/adverse effects
- Imidazoles/therapeutic use
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Male
- Middle Aged
- Philadelphia Chromosome
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/enzymology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/genetics
- Progression-Free Survival
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/adverse effects
- Protein Kinase Inhibitors/therapeutic use
- Pyridazines/administration & dosage
- Pyridazines/adverse effects
- Pyridazines/therapeutic use
- Risk Assessment
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Affiliation(s)
- Susanne Saussele
- Department of Haematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany,
| | - Wilhelm Haverkamp
- Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Fabian Lang
- Department of Medicine, Hematology and Oncology, Goethe University Frankfurt, Frankfurt, Germany
| | - Steffen Koschmieder
- Department of Medicine, Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Alexander Kiani
- Department of Medicine IV, Klinikum Bayreuth GmbH, Bayreuth, Germany
| | | | - Frank Stegelmann
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Heike Pfeifer
- Department of Medicine, Hematology and Oncology, Goethe University Frankfurt, Frankfurt, Germany
| | - Paul La Rosée
- Department of Medicine II, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Nicola Goekbuget
- Department of Medicine, Hematology and Oncology, Goethe University Frankfurt, Frankfurt, Germany
| | - Christina Rieger
- Hemato-Oncology Germering, Germering, Germany and Ludwig Maximilians University Munich, Munich, Germany
| | - Cornelius F Waller
- Department of Haematology, Oncology and Stem Cell Transplantation, University Medical Centre Freiburg, and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Philipp le Coutre
- Department of Medicine, Hematology and Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Rudolf Kirchmair
- Department of Internal Medicine III: Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | - Christian Junghanss
- Department of Medicine, Clinic III: Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Rostock, Germany
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García-Gutiérrez V, Hernández-Boluda JC. Tyrosine Kinase Inhibitors Available for Chronic Myeloid Leukemia: Efficacy and Safety. Front Oncol 2019; 9:603. [PMID: 31334123 PMCID: PMC6617580 DOI: 10.3389/fonc.2019.00603] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/18/2019] [Indexed: 12/25/2022] Open
Abstract
Chronic myeloid leukemia (CML) is currently a disease in which patients can enjoy a near normal life-expectancy. However, since the majority of patients will need to remain on treatment indefinitely, physicians in care of CML patients need be familiar with the indications and toxicities of all approved tyrosine kinase inhibitors (TKI). In clinical practice, there are five TKI (imatinib, nilotinib, dasatinib, bosutinib, and ponatinib) that are available in different scenarios and have distinct safety profiles. Decisions regarding first line treatment must be based on CML risk, comorbidities, and patients expectations. Despite the excellent outcome, half of the patients will eventually fail (due to intolerance or resistance) to first line treatment, with many of them requiring a third or even further lines of therapy. When selecting for such patients, it is essential to distinguish between failure and intolerance to previous TKIs. In the present review, we will address all these issues from a practical point of view.
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Affiliation(s)
- Valentín García-Gutiérrez
- Servicio de Hematología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Juan Carlos Hernández-Boluda
- Servicio de Hematología, Hospital Clínico Universitario, Institute of Health Research (INCLIVA), Valencia, Spain
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Caocci G, Mulas O, Abruzzese E, Luciano L, Iurlo A, Attolico I, Castagnetti F, Galimberti S, Sgherza N, Bonifacio M, Annunziata M, Gozzini A, Orlandi EM, Stagno F, Binotto G, Pregno P, Fozza C, Trawinska MM, De Gregorio F, Cattaneo D, Albano F, Gugliotta G, Baratè C, Scaffidi L, Elena C, Pirillo F, Scalzulli E, La Nasa G, Foà R, Breccia M. Arterial occlusive events in chronic myeloid leukemia patients treated with ponatinib in the real-life practice are predicted by the Systematic Coronary Risk Evaluation (SCORE) chart. Hematol Oncol 2019; 37:296-302. [PMID: 30892724 PMCID: PMC6766852 DOI: 10.1002/hon.2606] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/14/2019] [Indexed: 01/13/2023]
Abstract
Arterial occlusive events (AOEs) represent emerging complications in chronic myeloid leukemia (CML) patients treated with ponatinib. We identified 85 consecutive CML adult patients who were treated with ponatinib in 17 Italian centers. Patients were stratified according to the Systematic Coronary Risk Evaluation (SCORE) assessment, based on sex, age, smoking habits, systolic blood pressure, and total cholesterol levels. The 60‐month cumulative incidence rate of AOEs excluding hypertension was 25.7%. Hypertension was reported in 14.1% of patients. The median time of exposure to ponatinib was 28 months (range, 3‐69 months). Patients with a high to very high SCORE risk showed a significantly higher incidence rate of AOEs (74.3% vs 15.2%, P < 0.001). Patients aged ≥60 years showed a significantly higher incidence rate of AOEs (51.5% vs 16.9%, P = 0.008). In multivariate analysis, no association was found between AOEs and positive history of CV disease, age, dose of ponatinib, previous exposure to nilotinib, and comorbidities. Only the SCORE risk was confirmed as a significant predictive factor (P = 0.01; HR = 10.9; 95% C.I. = 1.7‐67.8). Patients aged ≥60 years who were treated with aspirin had a lower incidence rate of AOEs (33.3% vs 61.8%). Among the 14 reported AOEs, 78.6% of them showed grade 3 to 4 toxicity. This real‐life study confirmed the increased incidence of AOEs in CML patients treated with ponatinib, with high to very high SCORE risk. We suggest that patients aged ≥60 years who were treated with ponatinib should undergo prophylaxis with 100 mg/day of aspirin. Our findings emphasize personalized prevention strategies based on CV risk factors.
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Affiliation(s)
- Giovanni Caocci
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Olga Mulas
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Luigiana Luciano
- Hematology Unit "Federico II" University of Naples, Naples, Italy
| | - Alessandra Iurlo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Immacolata Attolico
- Department of Emergency and Organ Transplantation-Hematology Section, University of Bari, Bari, Italy
| | - Fausto Castagnetti
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Nicola Sgherza
- Hematology and Transplant Center, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | | | | | - Antonella Gozzini
- Hematology Unit, AOU Careggi, University of Florence, Florence, Italy
| | - Ester Maria Orlandi
- Division of Hematology, "Fondazione IRCCS Policlinico S. Matteo", Pavia, Italy
| | - Fabio Stagno
- Hematology Unit, AOU Policlinico-V. Emanuele, Rodolico Hospital, Catania, Italy
| | | | - Patrizia Pregno
- Hematology Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Claudio Fozza
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | | | | | - Daniele Cattaneo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Albano
- Department of Emergency and Organ Transplantation-Hematology Section, University of Bari, Bari, Italy
| | - Gabriele Gugliotta
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudia Baratè
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Luigi Scaffidi
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Chiara Elena
- Division of Hematology, "Fondazione IRCCS Policlinico S. Matteo", Pavia, Italy
| | - Francesca Pirillo
- Hematology Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Emilia Scalzulli
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | - Giorgio La Nasa
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Robin Foà
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
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