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Wang F, Qiu T, Wang H, Yang Q. State-of-the-Art Review on Myelofibrosis Therapies. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e350-e362. [PMID: 34903489 DOI: 10.1016/j.clml.2021.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 06/14/2023]
Abstract
Myelofibrosis (MF) is a BCR-ABL1-negative myeloproliferative neoplasm characterized by anemia, extramedullary hematopoiesis, bone marrow fibrosis, splenomegaly, constitutional symptoms and acute myeloid leukemia progression. Currently, allogeneic haematopoietic stem cell transplantation (AHSCT) therapy is the only curative option for MF patients. However, AHSCT is strictly limited due to the high rates of morbidity and mortality. Janus kinase 2 (JAK2) inhibitor Ruxolitinib is the first-line treatment for intermediate-II or high-risk MF patients with splenomegaly and constitutional symptoms, but most MF patients develop resistance or intolerance to Ruxolitinib. Therefore, MF treatment is a challenge for the medical community. This review summarizes 3 investigated directions for MF therapy: monotherapies of JAK inhibitors, monotherapies of non-JAK targeted agents, combination therapies of Ruxolitinib and other agents. We emphasize combination of Ruxolitinib and other agents is a promising strategy.
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Affiliation(s)
- Fuping Wang
- Beijing Key Laboratory of Resistant Gene Resources and Molecular Development, College of Life Sciences, Beijing Normal University, Beijing, China
| | - Tian Qiu
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Wang
- Department of Hematology, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Qiong Yang
- Beijing Key Laboratory of Resistant Gene Resources and Molecular Development, College of Life Sciences, Beijing Normal University, Beijing, China.
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Chifotides HT, Bose P, Masarova L, Pemmaraju N, Verstovsek S. SOHO State of the Art Updates and Next Questions: Novel Therapies in Development for Myelofibrosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:210-223. [PMID: 34840087 DOI: 10.1016/j.clml.2021.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 06/13/2023]
Abstract
Myeloproliferative neoplasms research has entered a dynamic and exciting era as we witness exponential growth of novel agents in advanced/early phase clinical trials for myelofibrosis (MF). Building on the success and pivotal role of ruxolitinib, many novel agents, spanning a wide range of mechanisms/targets (epigenetic regulation, apoptotic/intracellular signaling pathways, telomerase, bone marrow fibrosis) are in clinical development; several are studied in registrational trials and hold great potential to expand the therapeutic arsenal/shift the treatment paradigm if regulatory approval is granted. Insight into MF pathogenesis and its molecular underpinnings, preclinical studies demonstrating synergism of ruxolitinib with investigational agents, urgent unmet clinical needs (cytopenias, loss of response to JAK inhibitors); and progressive disease fueled the rapid rise of innovative therapeutics. New strategies include pairing ruxolitinib with erythroid maturation agents to manage anemia (luspatercept), designing rational combinations with ruxolitinib to boost responses in both the frontline and suboptimal response settings (pelabresib, navitoclax, parsaclisib), treatment with non-JAK inhibitor monotherapy in the second-line setting (navtemadlin, imetelstat), novel JAK inhibitors tailored to subgroups with challenging unmet needs (momelotinib and pacritinib for anemia and thrombocytopenia, respectively); and agents potentially enhancing longevity (imetelstat). Beyond typical endpoints evaluated in MF clinical trials (spleen volume reduction ≥ 35%, total symptom score reduction ≥ 50%) thus far, emerging endpoints include overall survival, progression-free survival, transfusion independence, anemia benefits, bone marrow fibrosis and driver mutation allele burden reduction. Novel biomarkers and additional clinical features are being sought to assess new agents and tailor emerging therapies to appropriate patients. New strategies are needed to optimize the design of clinical trials comparing novel combinations to standard agent monotherapy.
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Affiliation(s)
- Helen T Chifotides
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Lucia Masarova
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX.
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Chifotides HT, Bose P, Verstovsek S. Momelotinib: an emerging treatment for myelofibrosis patients with anemia. J Hematol Oncol 2022; 15:7. [PMID: 35045875 PMCID: PMC8772195 DOI: 10.1186/s13045-021-01157-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 12/11/2022] Open
Abstract
The suite of marked anemia benefits that momelotinib has consistently conferred on myelofibrosis (MF) patients stem from its unique inhibitory activity on the BMP6/ACVR1/SMAD and IL-6/JAK/STAT3 pathways, resulting in decreased hepcidin (master iron regulator) expression, higher serum iron and hemoglobin levels, and restored erythropoiesis. Clinical data on momelotinib from the phase 2 and the two phase 3 SIMPLIFY trials consistently demonstrated high rates of sustained transfusion-independence. In a recent phase 2 translational study, 41% of the patients achieved transfusion independence for ≥ 12 weeks. In the phase 3 trials SIMPLIFY-1 and SIMPLIFY-2, 17% more JAK inhibitor-naïve patients and two-fold more JAK inhibitor-treated patients achieved or maintained transfusion independence with momelotinib versus ruxolitinib and best available therapy (89% ruxolitinib), respectively. Anemia is present in approximately a third of MF patients at diagnosis, eventually developing in nearly all patients. The need for red blood cell transfusions is an independent adverse risk factor for both overall survival and leukemic transformation. Presently, FDA-approved medications to address anemia are lacking. Momelotinib is one of the prime candidates to durably address the critical unmet needs of MF patients with moderate/severe anemia. Importantly, momelotinib may have overall survival benefits in frontline and second-line MF patients. MOMENTUM is an international registration-track phase 3 trial further assessing momelotinib’s unique constellation of anemia and other benefits in second-line MF patients; the results of the MOMENTUM trial are keenly awaited and may lead to regulatory approval of momelotinib.
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Efficacy and safety of a novel dosing strategy for ruxolitinib in the treatment of patients with myelofibrosis and anemia: the REALISE phase 2 study. Leukemia 2021; 35:3455-3465. [PMID: 34017073 PMCID: PMC8632662 DOI: 10.1038/s41375-021-01261-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 03/25/2021] [Accepted: 04/26/2021] [Indexed: 12/14/2022]
Abstract
Anemia is a frequent manifestation of myelofibrosis (MF) and there is an unmet need for effective treatments in anemic MF patients. The REALISE phase 2 study (NCT02966353) evaluated the efficacy and safety of a novel ruxolitinib dosing strategy with a reduced starting dose with delayed up-titration in anemic MF patients. Fifty-one patients with primary MF (66.7%), post-essential thrombocythemia MF (21.6%), or post-polycythemia vera MF (11.8%) with palpable splenomegaly and hemoglobin <10 g/dl were included. Median age was 67 (45–88) years, 41.2% were female, and 18% were transfusion-dependent. Patients received 10 mg ruxolitinib b.i.d. for the first 12 weeks, then up-titrations of up to 25 mg b.i.d. were permitted, based on efficacy and platelet counts. Overall, 70% of patients achieved a ≥50% reduction in palpable spleen length at any time during the study. The most frequent adverse events leading to dose interruption/adjustment were thrombocytopenia (17.6%) and anemia (11.8%). Patients who had a dose increase had greater spleen size and higher white blood cell counts at baseline. Median hemoglobin levels remained stable and transfusion requirements did not increase compared with baseline. These results reinforce the notion that it is unnecessary to delay or withhold ruxolitinib because of co-existent or treatment-emergent anemia.
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Flick AC, Leverett CA, Ding HX, McInturff E, Fink SJ, Mahapatra S, Carney DW, Lindsey EA, DeForest JC, France SP, Berritt S, Bigi-Botterill SV, Gibson TS, Liu Y, O'Donnell CJ. Synthetic Approaches to the New Drugs Approved during 2019. J Med Chem 2021; 64:3604-3657. [PMID: 33783211 DOI: 10.1021/acs.jmedchem.1c00208] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
New drugs introduced to the market are privileged structures having affinities for biological targets implicated in human diseases and conditions. These new chemical entities (NCEs), particularly small molecules and antibody-drug conjugates, provide insight into molecular recognition and simultaneously function as leads for the design of future medicines. This review is part of a continuing series presenting the most likely process-scale synthetic approaches to 40 NCEs approved for the first time anywhere in the world in 2019.
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Affiliation(s)
- Andrew C Flick
- Takeda Pharmaceuticals, 9625 Towne Centre Drive, San Diego, California 92121, United States
| | - Carolyn A Leverett
- Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Hong X Ding
- Pharmacodia (Beijing) Co., Ltd., Beijing 100085, China
| | - Emma McInturff
- Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Sarah J Fink
- Takeda Pharmaceuticals, 125 Binney Street, Cambridge, Massachusetts 02142, United States
| | - Subham Mahapatra
- Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Daniel W Carney
- Takeda Pharmaceuticals, 9625 Towne Centre Drive, San Diego, California 92121, United States
| | - Erick A Lindsey
- Takeda Pharmaceuticals, 9625 Towne Centre Drive, San Diego, California 92121, United States
| | - Jacob C DeForest
- Pfizer Worldwide Research and Development, 10777 Science Center Drive, San Diego, California 92121, United States
| | - Scott P France
- Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Simon Berritt
- Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | | | - Tony S Gibson
- Takeda Pharmaceuticals, 9625 Towne Centre Drive, San Diego, California 92121, United States
| | - Yiyang Liu
- Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Christopher J O'Donnell
- Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, Connecticut 06340, United States
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