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Yacoub A, Twardowski N, Britt A, Shraim N. SOHO State of the Art Updates and Next Questions | Early Intervention in Myelofibrosis: Where Are We and Does It Matter? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:506-511. [PMID: 38553341 DOI: 10.1016/j.clml.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 07/30/2024]
Abstract
Historically, therapeutic clinical trials in myelofibrosis have predominantly focused on targeting patients with higher-risk disease who are at risk of increased morbidity and mortality. The endpoints have been designed to target regularly measured disease parameters that are of immediate pertinence to patient's welfare including splenic volume reduction and symptom reduction. These efforts have resulted in meaningful and measurable improvements in disease parameters in these high-risk study populations and multiple FDA approved agents. However, they have not tackled specific interventions that may be applied to patients with earlier or less advanced disease state. In this review, we summarize evidence from completed and ongoing clinical trials investigating different aspects of intervention targeted at less advanced disease and advocate for the merit of this approach.
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Affiliation(s)
| | | | - Alec Britt
- The University of Kansas Medical Center, Kansas City, KS
| | - Nour Shraim
- The University of Kansas Medical Center, Kansas City, KS
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2
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Passamonti F, Harrison CN, Mesa RA, Kiladjian JJ, Vannucchi AM, Verstovsek S. Anemia in myelofibrosis: current and emerging treatment options. Crit Rev Oncol Hematol 2022; 180:103862. [DOI: 10.1016/j.critrevonc.2022.103862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 10/17/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
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3
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Gerds AT, Gotlib J, Ali H, Bose P, Dunbar A, Elshoury A, George TI, Gundabolu K, Hexner E, Hobbs GS, Jain T, Jamieson C, Kaesberg PR, Kuykendall AT, Madanat Y, McMahon B, Mohan SR, Nadiminti KV, Oh S, Pardanani A, Podoltsev N, Rein L, Salit R, Stein BL, Talpaz M, Vachhani P, Wadleigh M, Wall S, Ward DC, Bergman MA, Hochstetler C. Myeloproliferative Neoplasms, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:1033-1062. [PMID: 36075392 DOI: 10.6004/jnccn.2022.0046] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The classic Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) consist of myelofibrosis, polycythemia vera, and essential thrombocythemia and are a heterogeneous group of clonal blood disorders characterized by an overproduction of blood cells. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for MPN were developed as a result of meetings convened by a multidisciplinary panel with expertise in MPN, with the goal of providing recommendations for the management of MPN in adults. The Guidelines include recommendations for the diagnostic workup, risk stratification, treatment, and supportive care strategies for the management of myelofibrosis, polycythemia vera, and essential thrombocythemia. Assessment of symptoms at baseline and monitoring of symptom status during the course of treatment is recommended for all patients. This article focuses on the recommendations as outlined in the NCCN Guidelines for the diagnosis of MPN and the risk stratification, management, and supportive care relevant to MF.
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Affiliation(s)
- Aaron T Gerds
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Haris Ali
- City of Hope National Medical Center
| | | | | | | | | | | | | | | | - Tania Jain
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | | | | | - Stephen Oh
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Brady L Stein
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Sarah Wall
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Dawn C Ward
- UCLA Jonsson Comprehensive Cancer Center; and
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Pastor-Galán I, Martín I, Ferrer B, Hernández-Boluda JC. Impact of molecular profiling on the management of patients with myelofibrosis. Cancer Treat Rev 2022; 109:102435. [PMID: 35839532 DOI: 10.1016/j.ctrv.2022.102435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/02/2022]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm (MPN) characterized by a highly heterogeneous clinical course, which can be complicated by severe constitutional symptoms, massive splenomegaly, progressive bone marrow failure, cardiovascular events, and development of acute leukemia. Constitutive signaling through the JAK-STAT pathway plays a fundamental role in its pathogenesis, generally due to activating mutations of JAK2, CALR and MPL genes (i.e., the MPN driver mutations), present in most MF patients. Next Generation Sequencing (NGS) panel testing has shown that additional somatic mutations can already be detected at the time of diagnosis in more than half of patients, and that they accumulate along the disease course. These mutations, mostly affecting epigenetic modifiers or spliceosome components, may cooperate with MPN drivers to favor clonal dominance or influence the clinical phenotype, and some, such as high molecular risk mutations, correlate with a more aggressive clinical course with poor treatment response. The current main role of molecular profiling in clinical practice is prognostication, principally for selecting high-risk patients who may be candidates for transplantation, the only curative treatment for MF to date. To this end, contemporary prognostic models incorporating molecular data are useful tools to discriminate different risk categories. Aside from certain clinical situations, decisions regarding medical treatment are not based on patient molecular profiling, yet this approach may become more relevant in novel treatment strategies, such as the use of vaccines against the mutant forms of JAK2 or CALR, or drugs directed against actionable molecular targets.
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Affiliation(s)
| | - Iván Martín
- Hospital Clínico Universitario-INCLIVA, Valencia, Spain
| | - Blanca Ferrer
- Hospital Clínico Universitario-INCLIVA, Valencia, Spain
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5
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Tefferi A, Gangat N, Pardanani A, Crispino JD. Myelofibrosis: Genetic Characteristics and the Emerging Therapeutic Landscape. Cancer Res 2022; 82:749-763. [PMID: 34911786 PMCID: PMC9306313 DOI: 10.1158/0008-5472.can-21-2930] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/18/2021] [Accepted: 11/30/2021] [Indexed: 01/07/2023]
Abstract
Primary myelofibrosis (PMF) is one of three myeloproliferative neoplasms (MPN) that are morphologically and molecularly inter-related, the other two being polycythemia vera (PV) and essential thrombocythemia (ET). MPNs are characterized by JAK-STAT-activating JAK2, CALR, or MPL mutations that give rise to stem cell-derived clonal myeloproliferation, which is prone to leukemic and, in case of PV and ET, fibrotic transformation. Abnormal megakaryocyte proliferation is accompanied by bone marrow fibrosis and characterizes PMF, while the clinical phenotype is pathogenetically linked to ineffective hematopoiesis and aberrant cytokine expression. Among MPN-associated driver mutations, type 1-like CALR mutation has been associated with favorable prognosis in PMF, while ASXL1, SRSF2, U2AF1-Q157, EZH2, CBL, and K/NRAS mutations have been shown to be prognostically detrimental. Such information has enabled development of exclusively genetic (GIPSS) and clinically integrated (MIPSSv2) prognostic models that facilitate individualized treatment decisions. Allogeneic stem cell transplantation remains the only treatment modality in MF with the potential to prolong survival, whereas drug therapy, including JAK2 inhibitors, is directed mostly at the inflammatory component of the disease and is therefore palliative in nature. Similarly, disease-modifying activity remains elusive for currently available investigational drugs, while their additional value in symptom management awaits controlled confirmation. There is a need for genetic characterization of clinical observations followed by in vitro and in vivo preclinical studies that will hopefully identify therapies that target the malignant clone in MF to improve patient outcomes.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.,Corresponding Author: Ayalew Tefferi, Division of Hematology, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Phone: 507-284-2511; Fax: 507-266-4972; E-mail:
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Animesh Pardanani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - John D. Crispino
- Division of Experimental Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
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How We Manage Myelofibrosis Candidates for Allogeneic Stem Cell Transplantation. Cells 2022; 11:cells11030553. [PMID: 35159362 PMCID: PMC8834299 DOI: 10.3390/cells11030553] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/01/2023] Open
Abstract
Moving from indication to transplantation is a critical process in myelofibrosis. Most of guidelines specifically focus on either myelofibrosis disease or transplant procedure, and, currently, no distinct indication for the management of MF candidates to transplant is available. Nevertheless, this period of time is crucial for the transplant outcome because engraftment, non-relapse mortality, and relapse incidence are greatly dependent upon the pre-transplant management. Based on these premises, in this review, we will go through the path of identification of the MF patients suitable for a transplant, by using disease-specific prognostic scores, and the evaluation of eligibility for a transplant, based on performance, comorbidity, and other combined tools. Then, we will focus on the process of donor and conditioning regimens’ choice. The pre-transplant management of splenomegaly and constitutional symptoms, cytopenias, iron overload and transplant timing will be comprehensively discussed. The principal aim of this review is, therefore, to give a practical guidance for managing MF patients who are potential candidates for allo-HCT.
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Bose P, Mesa RA. Novel strategies for challenging scenarios encountered in managing myelofibrosis. Leuk Lymphoma 2021; 63:774-788. [PMID: 34775887 DOI: 10.1080/10428194.2021.1999443] [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: 10/19/2022]
Abstract
Given its rarity, multi-faceted clinical presentation and the relative paucity of approved therapies, the management of myeloproliferative neoplasm (MPN)-associated myelofibrosis (MF) can be challenging. Janus kinase (JAK) inhibitors, the only approved agents at present, have brought many clinical benefits to patients, with prolongation of survival also demonstrated for ruxolitinib. However, these agents have clear limitations. Optimal management of anemia in MF remains a major unmet need. Neither ruxolitinib nor fedratinib is recommended for use in patients with severe thrombocytopenia, i.e. platelets <50 × 109/L, who have a particularly poor prognosis. The search for the optimal partner for JAK inhibitors to address some of the shortcomings of these agents (e.g. limited ability to improve bone marrow fibrosis, cytopenias and induce molecular responses) and achieve meaningful 'disease modification' continues. This has led to the development of a number of rational, preclinically synergistic combinations for use either upfront or in the setting of sub-optimal response to JAK inhibition. Finally, the outlook for patients whose disease progresses on JAK inhibitor therapy continues to be grim, and agents with alternative mechanisms of action may be needed in this setting. In this article, we use a case-based approach to illustrate challenges commonly encountered in clinical practice and our management of the same. Fortunately, there has been enormous growth in drug development efforts in the MF space in the last few years, some of which appear poised to bear fruit in the very near future.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ruben A Mesa
- Mays Cancer Center, UT Health San Antonio MD Anderson, San Antonio, TX, USA
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Kim SY, Bae SH, Bang SM, Eom KS, Hong J, Jang S, Jung CW, Kim HJ, Kim HY, Kim MK, Kim SJ, Mun YC, Nam SH, Park J, Won JH, Choi CW. The 2020 revision of the guidelines for the management of myeloproliferative neoplasms. Korean J Intern Med 2021; 36:45-62. [PMID: 33147902 PMCID: PMC7820646 DOI: 10.3904/kjim.2020.319] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/07/2020] [Indexed: 02/07/2023] Open
Abstract
In 2016, the World Health Organization revised the diagnostic criteria for myeloproliferative neoplasms (MPNs) based on the discovery of disease-driving genetic aberrations and extensive analysis of the clinical characteristics of patients with MPNs. Recent studies have suggested that additional somatic mutations have a clinical impact on the prognosis of patients harboring these genetic abnormalities. Treatment strategies have also advanced with the introduction of JAK inhibitors, one of which has been approved for the treatment of patients with myelofibrosis and those with hydroxyurea-resistant or intolerant polycythemia vera. Recently developed drugs aim to elicit hematologic responses, as well as symptomatic and molecular responses, and the response criteria were refined accordingly. Based on these changes, we have revised the guidelines and present the diagnosis, treatment, and risk stratification of MPNs encountered in Korea.
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Affiliation(s)
- Sung-Yong Kim
- Division of Hematology, Department of Internal Medicine, Konkuk University Medical Center, Seoul,
Korea
| | - Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu,
Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Ki-Seong Eom
- Department of Hematology, Seoul St. Mary’s Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Junshik Hong
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Chul Won Jung
- Division of Hematology/Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Ho Young Kim
- Department of Internal Medicine, Hallym University Medical Center, Anyang,
Korea
| | - Min Kyoung Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu,
Korea
| | - Soo-Jeong Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul,
Korea
| | - Yeung-Chul Mun
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul,
Korea
| | - Seung-Hyun Nam
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul,
Korea
| | - Jinny Park
- Division of Hematology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon,
Korea
| | - Jong-Ho Won
- Division of Hematology-Oncology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Chul Won Choi
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University Guro Hospital, Seoul,
Korea
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9
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Gerds AT. Myeloproliferative Neoplasms: Emerging Treatment Options for Myelofibrosis. J Natl Compr Canc Netw 2020. [DOI: 10.6004/jnccn.2020.5040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Myelofibrosis (MF) is a symptom-forward disease, and its treatment focuses on alleviating those symptoms, as well as improving survival. An initial disease risk assessment is critical for deciding on a course of therapy (and a number of models can be used depending on the available patient information), and anemia can be considered a special case within the treatment algorithms for MF. JAK-STAT inhibition is currently the cornerstone of treatment for MF, but these inhibitors are not perfect. Future research will focus on the microenvironment in reversing fibrosis, immunotherapies, proliferative signaling pathways, epigenetic regulators, and stem cells.
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10
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Asher S, McLornan DP, Harrison CN. Current and future therapies for myelofibrosis. Blood Rev 2020; 42:100715. [PMID: 32536371 DOI: 10.1016/j.blre.2020.100715] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/21/2019] [Accepted: 05/05/2020] [Indexed: 12/16/2022]
Abstract
Myelofibrosis is classified as a 'Philadelphia-chromosome negative' clonal myeloproliferative disorder. The heterogeneity of this condition and patient population and array of often challenging clinical manifestations can frequently make therapeutic decisions challenging. Despite many advances in therapy with targeted and combination approaches, following an enhanced understanding of underlying disease pathogenesis, cure only remains achievable with allogeneic stem cell transplant. This option is often limited to a small group of younger transplant-eligible patients with more advanced disease who have both a suitable donor and no or few co-morbidities. In this article, we will discuss up-to-date disease prognostication, common clinical challenges associated with myelofibrosis and both standard and novel therapeutic approaches. Increasingly complex prognostic modelling utilises patient-specific, haematological and genomic parameters to improve the accuracy of risk assessment and predict disease progression. We will also focus on difficult clinical scenarios such as disease-associated anaemia, thrombocytopenia and extremes of age. Future and evolving therapies within this field are highly anticipated and novel JAK inhibitor and non-JAK inhibitor-based therapy will also be discussed, including the new challenge of how to switch from one JAK inhibitor therapy to another.
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Affiliation(s)
- Samir Asher
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Donal P McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
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11
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Tavares RS, Nonino A, Pagnano KBB, Nascimento ACKVD, Conchon M, Fogliatto LM, Funke VAM, Bendit I, Clementino NCD, Chauffaille MDLLF, Bernardo WM, Santos FPDS. Guideline on myeloproliferative neoplasms: Associacão Brasileira de Hematologia, Hemoterapia e Terapia Cellular: Project guidelines: Associação Médica Brasileira - 2019. Hematol Transfus Cell Ther 2019; 41 Suppl 1:1-73. [PMID: 31248788 PMCID: PMC6630088 DOI: 10.1016/j.htct.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 12/22/2022] Open
Affiliation(s)
| | - Alexandre Nonino
- Instituto Hospital de Base do Distrito Federal (IHBDF), Brasília, DF, Brazil
| | | | | | | | | | | | - Israel Bendit
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | | | | | - Wanderley Marques Bernardo
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
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Abstract
PURPOSE OF REVIEW Cytopenias, particularly anemia, are frequently encountered in patients with myelofibrosis. Management of cytopenias in myelofibrosis can be very challenging because current therapeutic interventions are only of modest efficacy and ruxolitinib, the only approved drug for myelofibrosis, is myelosuppressive. Yet, dose optimization of ruxolitinib is important for its survival benefit in patients with advanced disease. We sought to summarize the data on treatments for cytopenias available at present and review promising agents in development and emerging strategies. RECENT FINDINGS The activin receptor ligand traps hold considerable promise for the treatment of anemia and could represent an attractive combination strategy with ruxolitinib. Low-dose thalidomide, which could offset both anemia and thrombocytopenia caused by ruxolitinib, represents another potential partner for ruxolitinib. The anti-fibrotic agent PRM-151 produced sustained improvements in cytopenias in some patients, and further data on this drug are eagerly awaited. Finally, several preclinical leads with translational potential are worthy of clinical investigation as strategies to halt/reverse bone marrow fibrosis and thereby improve cytopenias. Cytopenias remain a significant hurdle in myelofibrosis management, but several novel investigational agents hold considerable promise for the future.
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Maffioli M, Orlandi E, Passamonti F. Chronic myeloproliferative neoplasms in the elderly. Eur J Intern Med 2018; 58:33-42. [PMID: 29793825 DOI: 10.1016/j.ejim.2018.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 05/04/2018] [Indexed: 11/30/2022]
Abstract
This review focuses on the management of elderly patients with chronic myeloid leukemia and chronic myeloproliferative neoplasms, including polycythemia vera, essential thrombocythemia and primary myelofibrosis. Median age in these neoplasms is within the 6th decades of age. All new therapies can be done at any age without absolute contraindication. However, the selection of the precise therapy for the single patient is mandatory. For these reasons, an accurate definition of diagnosis and prognostication is necessary. Precision in disease definition and prognostication is definitively helpful for personalizing therapeutic approach.
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Affiliation(s)
- Margherita Maffioli
- Hematology, Department of Medicina Specialistica, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy
| | - Ester Orlandi
- Hematology, I.R.C.C.S Fondazione Policlinico San Matteo, Pavia, Italy
| | - Francesco Passamonti
- Hematology, Department of Medicina Specialistica, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy; Hematology, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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14
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Scherber RM, Mesa RA. Managing myelofibrosis (MF) that "blasts" through: advancements in the treatment of relapsed/refractory and blast-phase MF. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:118-126. [PMID: 30504300 PMCID: PMC6245993 DOI: 10.1182/asheducation-2018.1.118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Myelofibrosis (MF) is the most aggressive form of Philadelphia chromosome-negative myeloproliferative neoplasm, and it is complicated by severe symptom burden, thrombotic events, infections, cytopenias, and transformation to acute myeloid leukemia (AML). Ruxolitinib, the first-line therapy for symptomatic or intermediate- and high-prognostic risk MF, has improved overall survival for this population. However, approximately one-half of MF patients will discontinue ruxolitinib by the first few years of therapy due to a spectrum of resistance, intolerance, relapse, or progression to blast phase disease. Danazol, erythropoietin-stimulating agents, and spleen-directed therapies can be useful in the ruxolitinib-resistant setting. In the ruxolitinib-refractory or -intolerant setting, commercial and novel therapies, either alone or in combination with ruxolitinib, have shown clinical utility. For blast-phase MF, the recent advancements in available AML therapies have increased the options with targeted and more tolerable therapies. In this article, we will discuss our paradigm for the management of relapsed/refractory and blast-phase MF in the context of therapeutic advancements in both AML and MF.
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Affiliation(s)
- Robyn M. Scherber
- Department of Hematology and Oncology, Mays Cancer Center, University of Texas MD Anderson, University of Texas, San Antonio, TX; and
| | - Ruben A. Mesa
- Mays Cancer Center, University of Texas MD Anderson, University of Texas, San Antonio, TX
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15
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Crisà E, Cilloni D, Elli EM, Martinelli V, Palumbo GA, Pugliese N, Beggiato E, Frairia C, Cerrano M, Lanzarone G, Marchetti M, Mezzabotta M, Boccadoro M, Ferrero D. The use of erythropoiesis-stimulating agents is safe and effective in the management of anaemia in myelofibrosis patients treated with ruxolitinib. Br J Haematol 2018; 182:701-704. [DOI: 10.1111/bjh.15450] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 05/14/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Elena Crisà
- Haematology Division; A.O.U. Città della Salute e della Scienza di Torino; University of Turin; Torino Italy
| | - Daniela Cilloni
- Haematology Division; Department of Clinical and Biological Sciences; Ospedale San Luigi di Orbassano; University of Turin; Orbassano Italy
| | - Elena M. Elli
- Haematology Division; Ospedale San Gerardo; ASST Monza; Monza Italy
| | | | - Giuseppe A. Palumbo
- Haematology Division; A.O.U. Policlinico-V.Emanuele; University of Catania; Catania Italy
| | | | - Eloise Beggiato
- Haematology Division; A.O.U. Città della Salute e della Scienza di Torino; University of Turin; Torino Italy
| | - Chiara Frairia
- Haematology Division; Department of Translational Medicine; Azienda Ospedaliero-Universitaria Maggiore della Carita; Novara Italy
| | - Marco Cerrano
- Haematology Division; A.O.U. Città della Salute e della Scienza di Torino; University of Turin; Torino Italy
| | - Giuseppe Lanzarone
- Haematology Division; A.O.U. Città della Salute e della Scienza di Torino; University of Turin; Torino Italy
| | | | - Mauro Mezzabotta
- Haematology Division; Ordine Mauriziano - Ospedale Umberto I; Torino Italy
| | - Mario Boccadoro
- Haematology Division; A.O.U. Città della Salute e della Scienza di Torino; University of Turin; Torino Italy
| | - Dario Ferrero
- Haematology Division; A.O.U. Città della Salute e della Scienza di Torino; University of Turin; Torino Italy
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16
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Shreenivas A, Mascarenhas J. Emerging drugs for the treatment of Myelofibrosis. Expert Opin Emerg Drugs 2018; 23:37-49. [DOI: 10.1080/14728214.2018.1445718] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Aditya Shreenivas
- Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - John Mascarenhas
- Division of Hematology and Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
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Luo X, Xu Z, Li B, Qin T, Zhang P, Zhang H, Fang L, Pan L, Hu N, Qu S, Zhang Y, Huang G, Peter Gale R, Xiao Z. Thalidomide plus prednisone with or without danazol therapy in myelofibrosis: a retrospective analysis of incidence and durability of anemia response. Blood Cancer J 2018; 8:9. [PMID: 29335406 PMCID: PMC5802625 DOI: 10.1038/s41408-017-0029-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/10/2017] [Accepted: 10/13/2017] [Indexed: 11/25/2022] Open
Abstract
Low-dose thalidomide and prednisone alone or combined are effective therapies in some persons with primary myelofibrosis (PMF) and anemia with or with RBC transfusion dependence. Danazol is also effective in some persons with PMF and anemia. Responses to these drugs are typically incomplete and not sustained. It is unclear whether adding danazol to thalidomide and prednisone would improve efficacy. We retrospectively compared the outcomes of 88 subjects with PMF and anemia receiving thalidomide and prednisone without (n = 46) or with danazol (n = 42). The primary end point was anemia response, which was 71% (95% confidence interval (CI), 57, 85%) in subjects receiving thalidomide/prednisone/danazol compared with 46% (32, 60%; P = 0.014) in those receiving thalidomide/prednisone. Response rates in subjects who were RBC transfusion dependent was also higher in the danazol cohort (61% (38, 84%)) vs. 25% (6, 44%); P = 0.024). Time to response was rapid (median, 2 months (range, 1-11 months)) and similar between the cohorts. Response duration was longer in the thalidomide/prednisone/danazol cohort (HR 2.18 (1.18-5.42); P = 0.019). Adverse effects were mild and similar between the cohorts. In conclusion, thalidomide/prednisone/danazol seems superior to thalidomide/prednisone in persons with PMF and anemia. Our conclusion requires confirmation in a randomized trial.
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Affiliation(s)
- Xueping Luo
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Zefeng Xu
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Bing Li
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Tiejun Qin
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Peihong Zhang
- Department of Pathology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Hongli Zhang
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Liwei Fang
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Lijuan Pan
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Naibo Hu
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Shiqiang Qu
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yue Zhang
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Gang Huang
- Divisions of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robert Peter Gale
- Haematology Section, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, UK
| | - Zhijian Xiao
- MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China.
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China.
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Myelofibrosis-Related Anemia: Current and Emerging Therapeutic Strategies. Hemasphere 2017; 1:e1. [PMID: 31723730 PMCID: PMC6745971 DOI: 10.1097/hs9.0000000000000001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/20/2017] [Indexed: 12/15/2022] Open
Abstract
Myelofibrosis (MF) is a clonal hematopoietic stem cell disorder characterized by pathological myeloproliferation and aberrant cytokine production resulting in progressive fibrosis, inflammation, and functional compromise of the bone marrow niche. Patients with MF develop splenomegaly (due to extramedullary hematopoiesis), hypercatabolic symptoms (due to overexpression of inflammatory cytokines), and anemia (due to bone marrow failure and splenic sequestration). MF remains curable only with allogeneic hematopoietic stem cell transplantation (ASCT), a therapy that few MF patients are deemed fit to undergo. The goals of treatment are thus often palliative. The approval of the JAK inhibitor ruxolitinib has done much to address the burden of splenomegaly and constitutional symptoms of patients with MF; however, therapy-related anemia is often an anticipated downside. Anemia thus remains a challenge in the management of MF and represents a major unmet need. Intractable anemia depresses quality of life, portends poor outcomes, and can act to restrict access to palliative JAK inhibition in some patients. While therapies for MF-related anemia do exist, they are limited in their efficacy, durability, and tolerability. Therapies currently in development promise improved anemia-specific outcomes; however, are still early in the pathway to regulatory approval and regular clinical use. In this review, we will discuss established and emerging treatments for MF-related anemia. We will give particular attention to developmental therapies which herald significant progress in the understanding and management of MF-related anemia.
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Kuykendall AT, Talati C, Al Ali N, Sweet K, Padron E, Sallman DA, Lancet JE, List AF, Zuckerman KS, Komrokji RS. The Treatment Landscape of Myelofibrosis Before and After Ruxolitinib Approval. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:e45-e53. [PMID: 28869184 DOI: 10.1016/j.clml.2017.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/01/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION/BACKGROUND Myelofibrosis (MF) is a chronic myeloproliferative neoplasm that presents with a heterogeneous clinical phenotype and prognosis. Before the US Food and Drug Administration approval of ruxolitinib, treatment options were varied and had limited effect. The increased use of ruxolitinib has drastically altered the MF treatment landscape. In this study, we aimed to clarify the clinical situations in which ruxolitinib is being used and analyze its effect on this landscape. PATIENTS AND METHODS We retrospectively assessed treatment choices for MF patients treated at our institution (n = 309). This population was divided into 2 cohorts on the basis of a diagnosis before (cohort BR: n = 174) or after (cohort AR: n = 135) ruxolitinib approval. Cohorts were further stratified for comparison according to presenting clinical factors. RESULTS Expectedly, the first-line use of ruxolitinib markedly increased after its approval. AR patients were less likely to receive erythropoiesis-stimulating agents (ESAs; P = .0003) and thalidomide (P = .003) than BR patients. In patients with MF-related symptoms and/or splenomegaly, increased use of ruxolitinib was associated with decreased use of first-line ESA (P = .03) or thalidomide (P = .03). In anemic patients, increased use of first-line ruxolitinib was associated with a decreased use of thalidomide (P = .007). In patients with severe leukocytosis, ruxolitinib use did not significantly increase and hydroxyurea was the preferred first-line agent. CONCLUSION Overall, the increased use of ruxolitinib appears to have come predominantly at the expense of thalidomide and ESAs, while not having a large effect on the first-line use of hydroxyurea.
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Affiliation(s)
- Andrew T Kuykendall
- Department of Internal Medicine, Hematology & Medical Oncology Fellowship Program at Moffitt Cancer Center, University of South Florida, Tampa, FL.
| | - Chetasi Talati
- Department of Internal Medicine, Hematology & Medical Oncology Fellowship Program at Moffitt Cancer Center, University of South Florida, Tampa, FL
| | - Najla Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kendra Sweet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jeffrey E Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Alan F List
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kenneth S Zuckerman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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20
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Ho PJ, Bajel A, Burbury K, Dunlop L, Durrant S, Forsyth C, Perkins AC, Ross DM. A case-based discussion of clinical problems in the management of patients treated with ruxolitinib for myelofibrosis. Intern Med J 2017; 47:262-268. [PMID: 28260257 DOI: 10.1111/imj.13341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022]
Abstract
Ruxolitinib is a dual janus kinase 1 (JAK1)/JAK2 inhibitor used to treat splenomegaly and symptoms associated with myelofibrosis (MF). Current therapeutic options for symptomatic MF include supportive care, myelosuppressive therapy (such as hydroxycarbamide) and janus kinase (JAK) inhibitors (in particular ruxolitinib). Allogeneic stem cell transplantation remains the only potentially curative treatment for MF, and younger transplant-eligible patients should still be considered for allogeneic stem cell transplantation; however, this is applicable only to a small proportion of patients. There is now increasing and extensive experience of the efficacy and safety of ruxolitinib in MF, both in clinical trials and in 'real-world' practice. The drug has been shown to be of benefit in intermediate-1 risk patients with symptomatic splenomegaly or other MF-related symptoms, and higher risk disease. Optimal use of the drug is required to maximise clinical benefit, requiring an understanding of the balance between dose-dependent responses and dose-limiting toxicities. There is also increasing experience in the use of ruxolitinib in the pre-transplantation setting. This paper aims to utilise several 'real-life' cases to illustrate several strategies that may help to optimise clinical practice.
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Affiliation(s)
- P Joy Ho
- Royal Prince Alfred Hospital, and, Sydney, NSW, Australia.,University of Sydney, NSW, Sydney, NSW, Australia
| | - Ashish Bajel
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kate Burbury
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Lindsay Dunlop
- Liverpool Hospital, Sydney, NSW, Australia.,Western Sydney University, Sydney, NSW, Australia
| | - Simon Durrant
- Royal Brisbane Hospitals, Brisbane, Queensland, Australia
| | - Cecily Forsyth
- Jarrett Street Specialist Centre, North Gosford, NSW, Australia
| | - Andrew C Perkins
- Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Wesley Hospital, Brisbane, Queensland, Australia
| | - David M Ross
- SA Pathology, Royal Adelaide Hospital, Brisbane, South Australia, Australia.,Flinders Medical Centre, Adelaide, South Australia, Australia
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21
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Hernández-Boluda JC, Correa JG, García-Delgado R, Martínez-López J, Alvarez-Larrán A, Fox ML, García-Gutiérrez V, Pérez-Encinas M, Ferrer-Marín F, Mata-Vázquez MI, Raya JM, Estrada N, García S, Kerguelen A, Durán MA, Albors M, Cervantes F. Predictive factors for anemia response to erythropoiesis-stimulating agents in myelofibrosis. Eur J Haematol 2017; 98:407-414. [PMID: 28009442 DOI: 10.1111/ejh.12846] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Erythropoiesis-stimulating agents (ESAs) are commonly used to treat the anemia of myelofibrosis (MF), but information on the predictors of response is limited. METHODS Results of ESA therapy were analyzed in 163 MF patients with severe anemia, most of whom had inadequate erythropoietin (EPO) levels (<125 U/L) at treatment start. RESULTS According to the revised criteria of the International Working Group for Myelofibrosis Treatment and Research, anemia response was achieved in 86 patients (53%). Median response duration was 19.3 months. In multivariate analysis, baseline factors associated with a higher response rate were female sex (P=.007), leukocyte count ≥10×109 /L (P=.033), and serum ferritin <200 ng/mL (P=.002). Patients with 2 or 3 of the above features had a significantly higher response rate than the remainder (73% vs 28%, respectively; P<.001). Over the 373 patient-years of follow-up on ESA treatment, nine patients developed thrombotic complications (six arterial, three venous), accounting for 2.41 events per 100 patient-years. Survival time from ESA start was longer in anemia responders than in non-responders (P=.011). CONCLUSION Besides the already established predictive value of EPO levels, these data can help to identify which MF patients are more likely to benefit from ESA treatment.
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Affiliation(s)
| | - Juan-Gonzalo Correa
- Hematology Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | | | | | - María-Laura Fox
- Hematology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | - Francisca Ferrer-Marín
- Hematology and Medical Oncology Department, Hospital Morales Meseguer, IMIB-Arrixaca, UCAM, Murcia, Spain
| | | | - José-María Raya
- Hematology Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Natalia Estrada
- Hematology Department, Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Badalona, Spain
| | - Silvia García
- Hematology Department, Hospital La Fe, IIS La Fe, Valencia, Spain
| | - Ana Kerguelen
- Hematology Department, Hospital La Paz, Madrid, Spain
| | | | - Manuel Albors
- Hematology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Francisco Cervantes
- Hematology Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
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22
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Ross DM. Responses to pomalidomide and placebo in myelofibrosis-related anaemia. Leukemia 2016; 31:532-533. [PMID: 27932792 DOI: 10.1038/leu.2016.348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/31/2016] [Indexed: 01/08/2023]
Affiliation(s)
- D M Ross
- Haematology Directorate, SA Pathology, Adelaide, South Australia, Australia
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23
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Abstract
INTRODUCTION Primary myelofibrosis (PMF) is the least common but the most aggressive of the classic Philadelphia chromosome-negative myeloproliferative neoplasms. Survival is much shorter in PMF than in polycythemia vera (PV) or essential thrombocythemia (ET). Post-PV/ET myelofibrosis (MF) is clinically indistinguishable from PMF and approached similarly. Areas covered: Current pharmacologic therapy of MF revolves around the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib, which dramatically improves constitutional symptoms and splenomegaly in the majority of patients, and improves overall survival (OS). However, allogeneic stem cell transplantation remains the only potential cure. Other JAK inhibitors continue to be developed for MF, and momelotinib and pacritinib are in phase III clinical trials. Anemia is common in MF, and initially worsened by ruxolitinib. Momelotinib and pacritinib may prove advantageous in this regard. Current strategies for managing anemia of MF include danazol, immunomodulatory drugs and erythroid stimulating agents, either alone or in combination with ruxolitinib. Expert opinion: A number of other agents, representing diverse drug classes, are in various stages of development for MF. These include newer JAK inhibitors, other signaling inhibitors, epigenetic modifiers, anti-fibrotic agents, telomerase inhibitors, and activin receptor ligand traps (for anemia). Hopefully, these novel therapies will further extend the clinical benefits of ruxolitinib.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
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Abstract
Myelofibrosis (MF) is a myeloproliferative neoplasm that presents either as a primary disease or evolves secondarily from polycythemia vera or essential thrombocythemia to post-polycythemia vera MF or post-essential thrombocythemia MF, respectively. Myelofibrosis is characterized by stem cell-derived clonal myeloproliferation, abnormal cytokine expression, bone marrow fibrosis, anemia, splenomegaly, extramedullary hematopoiesis, constitutional symptoms, cachexia, leukemic progression, and shortened survival. Therapeutic options for patients with MF have been limited to the use of cytoreductive agents, predominantly hydroxyurea; splenectomy and splenic irradiation for treatment of splenomegaly; and management of anemia with transfusions, erythropoiesis-stimulating agents, androgens, and immunomodulatory agents along with steroids. The only curative option is allogeneic stem cell transplantation (ASCT), which is associated with high morbidity and mortality risks. Recently, JAK (Janus kinase) inhibitor therapies have become available and proven to be palliative in primary MF patients with hydroxyurea-refractory splenomegaly and severe constitutional symptoms. The purpose of this article is to review the clinical features of MF; discuss different treatment strategies, including ASCT; and discuss the potential danger and benefit of using JAK inhibitors prior to ASCT.
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A randomized study of pomalidomide vs placebo in persons with myeloproliferative neoplasm-associated myelofibrosis and RBC-transfusion dependence. Leukemia 2016; 31:896-902. [PMID: 27773929 PMCID: PMC5383927 DOI: 10.1038/leu.2016.300] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/02/2016] [Accepted: 09/19/2016] [Indexed: 01/08/2023]
Abstract
RBC-transfusion dependence is common in persons with myeloproliferative neoplasm (MPN)-associated myelofibrosis. The objective of this study was to determine the rates of RBC-transfusion independence after therapy with pomalidomide vs placebo in persons with MPN-associated myelofibrosis and RBC-transfusion dependence. Two hundred and fifty-two subjects (intent-to-treat (ITT) population) including 229 subjects confirmed by central review (modified ITT population) were randomly assigned (2:1) to pomalidomide or placebo. Trialists and subjects were blinded to treatment allocation. Primary end point was proportion of subjects achieving RBC-transfusion independence within 6 months. One hundred and fifty-two subjects received pomalidomide and 77 placebo. Response rates were 16% (95% confidence interval (CI), 11, 23%) vs 16% (8, 26% P=0.87). Response in the pomalidomide cohort was associated with ⩽4 U RBC/28 days (odds ratio (OR)=3.1; 0.9, 11.1), age ⩽65 (OR=2.3; 0.9, 5.5) and type of MPN-associated myelofibrosis (OR=2.6; 0.7, 9.5). Responses in the placebo cohort were associated with ⩽4 U RBC/28 days (OR=8.6; 0.9, 82.3), white blood cell at randomization >25 × 109/l (OR=4.9; 0.8, 28.9) and interval from diagnosis to randomization >2 years (OR=4.9; 1.1, 21.9). Pomalidomide was associated with increased rates of oedema and neutropenia but these adverse effects were manageable. Pomalidomide and placebo had similar RBC-transfusion-independence response rates in persons with MPN-associated RBC-transfusion dependence.
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Verstovsek S, Talpaz M, Ritchie E, Wadleigh M, Odenike O, Jamieson C, Stein B, Uno T, Mesa RA. A phase I, open-label, dose-escalation, multicenter study of the JAK2 inhibitor NS-018 in patients with myelofibrosis. Leukemia 2016; 31:393-402. [PMID: 27479177 PMCID: PMC5292677 DOI: 10.1038/leu.2016.215] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/24/2016] [Accepted: 07/04/2016] [Indexed: 12/13/2022]
Abstract
NS-018 is a Janus-activated kinase 2 (JAK2)-selective inhibitor, targeting the JAK–signal transducer and activator of transcription (STAT) pathway that is deregulated in myelofibrosis. In this phase I, dose-escalation portion of a phase I/II study, patients with myelofibrosis received oral NS-018 in continuous 28-day cycles. The primary study objective was to evaluate safety, tolerability and clinically active dose of NS-018. Forty-eight patients were treated; 23 (48%) had previously received a JAK inhibitor (JAKi). The most common drug-related adverse events were thrombocytopenia (27%)/anemia (15%) for hematologic events, and dizziness (23%)/nausea (19%) for non-hematologic events. Once daily NS-018 at 300 mg was chosen as the phase II study dose based on improved tolerability compared with higher doses. A ⩾50% reduction in palpable spleen size was achieved in 56% of patients (47% of patients with prior JAKi treatment), and improvements were observed in myelofibrosis-associated symptoms. Bone marrow fibrosis grade (local assessment) improved from baseline in 11/30 evaluable patients (37%) after 3 cycles of NS-018. JAK2 allele burden was largely unchanged. Changes in cytokine/protein levels were noted after 4 weeks of treatment. NS-018 reached peak plasma concentration in 1–2 h and did not accumulate with multiple dosing. NS-018 will be assessed in patients with previous JAKi exposure in the phase II portion.
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Affiliation(s)
- S Verstovsek
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - M Talpaz
- Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - E Ritchie
- Division of Hematology and Medical Oncology, Cornell University, New York, NY, USA
| | - M Wadleigh
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - O Odenike
- University of Chicago Medical Center, Chicago, IL, USA
| | - C Jamieson
- Moores Cancer Center, University of California, San Diego, CA, USA
| | - B Stein
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - T Uno
- NS Pharma Inc., Paramus, NJ, USA
| | - R A Mesa
- Mayo Clinic, Scottsdale, AZ, USA
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Al-Ali HK, Vannucchi AM. Managing patients with myelofibrosis and low platelet counts. Ann Hematol 2016; 96:537-548. [PMID: 27209535 DOI: 10.1007/s00277-016-2697-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/10/2016] [Indexed: 12/18/2022]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm characterized by bone marrow fibrosis, ineffective hematopoiesis, splenomegaly, constitutional symptoms, and shortened survival. Patients often experience multiple disease-associated, as well as treatment-emergent, cytopenias, including thrombocytopenia. However, patients with MF with thrombocytopenia have few therapeutic options, and there is little information on the management of these patients. Several Janus kinase (JAK) inhibitors have been developed for the treatment of MF, with one (ruxolitinib) having been approved. However, given their mechanism of action, JAK inhibitors are associated with high rates of thrombocytopenia. Patients can be successfully managed with dose modifications, but little is known about the safety and efficacy of these agents in patients with thrombocytopenia. Recent studies of JAK inhibitors in patients with MF who have low platelet counts have had mixed results. This review discusses the prevalence, prognostic implications, and management of thrombocytopenia in MF and the different therapeutic options available for this patient population, with an emphasis on current clinical experience with targeted therapies, as well as recent findings from several clinical studies currently underway.
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Affiliation(s)
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Alimam S, Harrison C. Is there a role for pomalidomide in the treatment of myelofibrosis? Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1171139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Primary myelofibrosis: current therapeutic options. Rev Bras Hematol Hemoter 2016; 38:257-63. [PMID: 27521865 PMCID: PMC4997889 DOI: 10.1016/j.bjhh.2016.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/05/2016] [Indexed: 12/24/2022] Open
Abstract
Primary myelofibrosis is a Philadelphia-negative myeloproliferative neoplasm characterized by clonal myeloid expansion, followed by progressive fibrous connective tissue deposition in the bone marrow, resulting in bone marrow failure. Clonal evolution can also occur, with an increased risk of transformation to acute myeloid leukemia. In addition, disabling constitutional symptoms secondary to the high circulating levels of proinflammatory cytokines and hepatosplenomegaly frequently impair quality of life. Herein the main current treatment options for primary myelofibrosis patients are discussed, contemplating disease-modifying therapeutics in addition to palliative measures, in an individualized patient-based approach.
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Cervantes F, Correa JG, Hernandez-Boluda JC. Alleviating anemia and thrombocytopenia in myelofibrosis patients. Expert Rev Hematol 2016; 9:489-96. [DOI: 10.1586/17474086.2016.1154452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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31
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Vannucchi AM, Barbui T, Cervantes F, Harrison C, Kiladjian JJ, Kröger N, Thiele J, Buske C. Philadelphia chromosome-negative chronic myeloproliferative neoplasms: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015; 26 Suppl 5:v85-99. [PMID: 26242182 DOI: 10.1093/annonc/mdv203] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
MESH Headings
- Humans
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/diagnosis
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/pathology
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/therapy
- Philadelphia Chromosome
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Affiliation(s)
- A M Vannucchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence
| | - T Barbui
- Hematology and Foundation for Research, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - F Cervantes
- Department of Hematology, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - C Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J-J Kiladjian
- Centre d'Investigations Cliniques (INSERM CIC1427), Hôpital Saint-Louis and Paris Diderot University, Paris, France
| | - N Kröger
- Department of Stem Cell Transplantation, University Hospital Hamburg, Hamburg
| | | | - C Buske
- Comprehensive Cancer Center Ulm, Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
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El Fakih R, Popat U. Janus Kinase Inhibitors and Stem Cell Transplantation in Myelofibrosis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15 Suppl:S34-42. [PMID: 26297276 DOI: 10.1016/j.clml.2015.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/05/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
Myelofibrosis (MF) is characterized by splenomegaly, blood count abnormalities, particularly cytopenias, and a propensity for transformation to acute leukemia. The current treatment approach is to ameliorate symptoms due to these abnormalities. Treatment with Janus kinase 2 inhibitors reduces spleen size and improves symptoms in patients with MF, but most of the patients eventually have disease progression and stop responding. Allogeneic stem cell transplantation remains the only curative option. However, its efficacy must be balanced against the risk of treatment-related death and long-term sequelae of transplant like chronic graft versus host disease. The challenge is to integrate treatment with Janus kinase inhibitors with allogeneic stem cell transplantation.
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Affiliation(s)
- Riad El Fakih
- Department of Stem Cell Transplantation, The University of Texas M.D. Anderson Cancer Center, Houston, TX.
| | - Uday Popat
- Department of Stem Cell Transplantation, The University of Texas M.D. Anderson Cancer Center, Houston, TX
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Danazol therapy for the anemia of myelofibrosis: assessment of efficacy with current criteria of response and long-term results. Ann Hematol 2015; 94:1791-6. [DOI: 10.1007/s00277-015-2435-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/21/2015] [Indexed: 10/23/2022]
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Abstract
Myelofibrosis (MF), including primary, post-essential thrombocythemia and post-polycythemia vera MF, associates with a reduced quality of life and shortened life expectancy. Dysregulation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway is prominent, even in the absence of the JAK2(V617F) mutation. Therefore, all symptomatic MF patients may potentially derive benefit from JAK inhibitors. Despite the efficacy of JAK inhibitors in controlling signs and symptoms of MF, they do not eradicate the disease. Therefore, JAK inhibitors are currently being tested in combination with other novel therapies, a strategy which may be more effective in reducing disease burden, either by overcoming JAK inhibitor resistance or targeting additional mechanisms of pathogenesis. Additional targets include modulators of epigenetic regulation, pathways that work downstream from JAK/STAT (i.e. mammalian target of rapamycin/AKT/phosphoinositide 3-kinase) heat shock protein 90, hedgehog signaling, pro-fibrotic factors, abnormal megakaryocytes and telomerase. In this review, we discuss novel MF therapeutic strategies.
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Affiliation(s)
- Brady L Stein
- a Northwestern University Feinberg School of Medicine , Chicago , IL , USA
- b Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago , IL , USA
| | - Francisco Cervantes
- c Hospital Clínic, Hematology Department, Institut d'Investigació Biomédica August Pi i Sunyer , University of Barcelona , Barcelona , Spain
| | - Francis Giles
- b Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago , IL , USA
| | - Claire N Harrison
- d Department of Haematology , Guy's and St. Thomas' National Health Service Foundation Trust , London , UK
| | - Srdan Verstovsek
- e Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
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Abstract
The classical myeloproliferative neoplasms (MPNs) are a group of clonal diseases comprising essential thrombocythaemia (ET), polycythaemia vera (PV) and primary myelofibrosis (PMF). PMF is the rarest disease sub type and has been challenging to address due to the lack of a specific genetic marker, inadequate risk identification models and a highly variable clinical course. Continuous efforts have over time, seen the inclusion of cytogenetic information in prognostic scoring models that have resulted in improved risk stratification models providing further rationale for therapeutic management. Technological advances using single nucleotide polymorphism arrays increased the detection of known and novel MPN related changes and variant detection by massively parallel sequencing provided a large scale screening tool for the multitude of somatic gene mutations that have more recently been described in MPN. Some of these mutations show an association with specific cytogenetic changes or phenotypes. While PMF occurs mainly in adults, it has also been described in paediatric cases and shows distinct histopathological, genetic and clinical features in comparison. This review provides an overview of the genomics landscape of PMF and current developments in MPN therapy.
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Affiliation(s)
- Nisha R Singh
- 1 Department of Genetics, Pathology North-Sydney, St Leonards, NSW, Australia ; 2 Kolling Institute, University of Sydney, NSW, Australia
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Kiladjian JJ. Current therapies and their indications for the Philadelphia-negative myeloproliferative neoplasms. Am Soc Clin Oncol Educ Book 2015:e389-e396. [PMID: 25993201 DOI: 10.14694/edbook_am.2015.35.e389] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The groundbreaking discovery of the Janus-associated kinase 2 (JAK2) V617F mutation 10 years ago resulted in an unprecedented intensive basic and clinical research in Philadelphia-negative myeloproliferative neoplasms (MPNs). During these years, many new potential targets for therapy were identified that opened the era of targeted therapy for these diseases. However, only one new drug (ruxolitinib) has been approved during the past 40 years, and, although promising new therapies are evaluated, the armamentarium to treat MPN still relies on conventional drugs, like cytotoxic agents and anagrelide. The exact role of interferon (IFN) alfa still needs to be clarified in randomized studies, although it has been shown to be effective in MPNs for more than 25 years. The current therapeutic strategy for MPNs is based on the risk of vascular complication, which is the main cause of mortality and mortality in the medium term. However, the long-term outcome may be different, with an increasing risk of transformation to myelodysplastic syndrome or acute leukemia during follow-up times. Medicines able to change this natural history have not been clearly identified yet, and allogeneic stem cell transplantation currently remains the unique curative approach, which is only justified for patients with high-risk myelofibrosis or for patients with MPNs that have transformed to myelodysplasia or acute leukemia.
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Abstract
PURPOSE The pharmacology, pharmacokinetics, pharmacogenomics, clinical efficacy, and safety profile of ruxolitinib for the treatment of primary myelofibrosis are reviewed. SUMMARY Ruxolitinib, an oral tyrosine kinase inhibitor that targets the Janus-associated kinases (JAKs) 1 and 2, has been recently approved for the treatment of patients with intermediate- or high-risk myelofibrosis. Unlike previous treatment options for patients with myelofibrosis, ruxolitinib offers a targeted therapy option for these patients who often suffer with severe and debilitating symptoms associated with the disease process. After oral administration, ruxolitinib is rapidly absorbed and can be given without regard to meals. Ruxolitinib is primarily metabolized by the cytochrome P-450 (CYP) 3A4 isoenzyme system; therefore, if concomitant use with a strong CYP3A4 inhibitor is unavoidable, an initial dosage reduction is warranted. Two Phase III randomized trials comparing ruxolitinib to either placebo or best available therapy found a rapid and sustained response in the reduction of spleen size and improvements in constitutional symptoms and quality of life, with one study demonstrating an improvement in overall survival. The most commonly reported serious adverse effects of ruxolitinib are anemia and thrombocytopenia. Ruxolitinib is administered as an oral tablet given twice daily, with the initial starting dosage based on the baseline platelet count. Dosage reductions are based on the development of thrombocytopenia. CONCLUSION By directly targeting both JAK1 and JAK2 through small-molecule inhibition, ruxolitinib elicits a reduction in splenomegaly and disease-related symptoms in patients with intermediate- or high-risk myelofibrosis while maintaining an acceptable toxicity profile and a low treatment-discontinuation rate.
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Affiliation(s)
- Starla J Swaim
- Starla J. Swaim, Pharm.D., BCOP, is Clinical Pharmacy Specialist, Leukemia, Division of Pharmacy, University of Texas, M. D. Anderson Cancer Center, Houston
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Salit RB, Deeg HJ. Role of hematopoietic stem cell transplantation in patients with myeloproliferative disease. Hematol Oncol Clin North Am 2014; 28:1023-35. [PMID: 25459177 DOI: 10.1016/j.hoc.2014.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Myeloproliferative neoplasms (MPN) are clonal hematopoietic stem cell disorders. While some MPN patients have an indolent course, all are at risk of progressing to severe marrow failure or transforming into acute leukemia. Allogeneic hematopoietic cell transplantation (allo-HCT) is the only potential curative therapy. Major pre-transplant risk factors are disease stage of the MPN, the presence of comorbid conditions and the use of HLA non-identical donors. The development of reduced-intensity conditioning regimens has allowed for successful allo-HCT even for older patients and patients with comorbid conditions. The pre-transplant use of JAK2 inhibitors, which may be effective in down staging a patient's disease, may improve the outcomes following allo-HCT.
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Affiliation(s)
- Rachel B Salit
- Clinical Research Division, Cord Blood Transplant Research Program, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; University of Washington Medical Center, Seattle, WA 98195, USA
| | - H Joachim Deeg
- Clinical Research Division, Cord Blood Transplant Research Program, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; University of Washington Medical Center, Seattle, WA 98195, USA.
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Abstract
Myelofibrosis (MF) is a BCR-ABL1-negative myeloproliferative neoplasm characterized by clonal myeloproliferation, dysregulated kinase signaling, and release of abnormal cytokines. In recent years, important progress has been made in the knowledge of the molecular biology and the prognostic assessment of MF. Conventional treatment has limited impact on the patients' survival; it includes a wait-and-see approach for asymptomatic patients, erythropoiesis-stimulating agents, androgens, or immunomodulatory agents for anemia, cytoreductive drugs such as hydroxyurea for the splenomegaly and constitutional symptoms, and splenectomy or radiotherapy in selected patients. The discovery of the Janus kinase (JAK)2 mutation triggered the development of molecular targeted therapy of MF. The JAK inhibitors are effective in both JAK2-positive and JAK2-negative MF; one of them, ruxolitinib, is the current best available therapy for MF splenomegaly and constitutional symptoms. However, although ruxolitinib has changed the therapeutic scenario of MF, there is no clear indication of a disease-modifying effect. Allogeneic stem cell transplantation remains the only curative therapy of MF, but due to its associated morbidity and mortality, it is usually restricted to eligible high- and intermediate-2-risk MF patients. To improve current therapeutic results, the combination of JAK inhibitors with other agents is currently being tested, and newer drugs are being investigated.
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Macciò A, Gramignano G, Madeddu C. Surprising results of a supportive integrated therapy in myelofibrosis. Nutrition 2014; 31:239-43. [PMID: 25466670 DOI: 10.1016/j.nut.2014.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Myelofibrosis (MF) is characterized by shortened survival and a greatly compromised quality of life. Weight loss and cachexia seem to be the most important factors influencing survival in patients with MF. The aim of this study was to assess the efficacy of an integrated supportive therapy in improving cachexia and MF-related symptoms. METHODS We reported on a case of a patient with MF who presented with weight loss and cachexia associated with severe anemia, fatigue, fever, and bone pain. The circulating levels of inflammatory, oxidative stress parameters, hepcidin, and erythropoietin were evaluated and were above normal ranges. The patient was treated with a multitargeted approach specifically developed for cachexia including oral l-carnitine, celecoxib, curcumin, lactoferrin, and subcutaneous recombinant human erythropoietin (EPO)-α. RESULTS Surprisingly, after 1 y, cachexia features improved, all MF symptoms were in remission, and inflammatory and oxidative stress parameters, hepcidin, and EPO were reduced. CONCLUSIONS Because our protocol was targeted at inflammation and the metabolic state, its effectiveness may emphasize the role of inflammation in the pathogenesis of MF symptoms and demonstrates a need for the study of new integrated therapeutic strategies.
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Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, A. Businco Hospital, Regional Referral Center for Cancer Diseases, Cagliari, Italy.
| | - Giulia Gramignano
- Division of Medical Oncology, NS Bonaria Hospital, San Gavino, Italy
| | - Clelia Madeddu
- Department of Medical Sciences "Mario Aresu", University of Cagliari, Italy
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Mascarenhas J. Rationale for combination therapy in myelofibrosis. Best Pract Res Clin Haematol 2014; 27:197-208. [PMID: 25189730 DOI: 10.1016/j.beha.2014.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 07/11/2014] [Indexed: 12/18/2022]
Abstract
Agents targeting the JAK-STAT pathway have dominated the investigational therapeutic portfolio over the last five years resulting in the first and only approved agent for the treatment of patients with myelofibrosis (MF). However, chromatin modifying agents, anti-fibrosing agents, and other signaling pathway inhibitors have also demonstrated activity and offer the potential to improve upon the clinical success of JAK2 inhibition. Due to the complex pathobiological mechanisms underlying MF, it is likely that a combination of biologically active therapies will be required to target the MF hematopoietic stem cell in order to achieve significant disease course modification. Ruxolitinib in partnership with panobinostat, decitabine, and LDE225 are being evaluated in current combination therapy trials based on pre-clinical studies that provide strong scientific rationale. The rationale of combination of danazol or lenalidomide with ruxolitinib is mainly based on mitigation of anti-JAK2-mediated myelosuppression. Combination trials of ruxolitinib and novel anti-fibrosing agents such as PRM-151 represent an attempt to address therapeutic limitations of JAK2 inhibitors such as reversal of bone marrow fibrosis. Ruxolitinib is also being incorporated in novel treatment strategies in the setting of hematopoietic stem cell transplantation for MF. As the pathogenetic mechanisms are better understood, potential drug combinations in MF will increase dramatically and demonstration of biologic activity in effective preclinical models will be required to efficiently evaluate the most active combinations with least toxicity in future trials. This manuscript will address the proposed goals of combination therapy approach and review the state of the art in combination experimental therapy for MF.
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Affiliation(s)
- John Mascarenhas
- Myeloproliferative Disorder Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, USA.
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Birgegård G. Does anything work for anaemia in myelofibrosis? Best Pract Res Clin Haematol 2014; 27:175-85. [PMID: 25189728 DOI: 10.1016/j.beha.2014.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/11/2014] [Indexed: 11/18/2022]
Abstract
Anaemia is a common finding at diagnosis in myelofibrosis, and becomes a symptomatic problem in most patients with time. There are several treatment options for specific anaemia treatment, none of which has been tested in large, randomized, controlled trials. However, as myelofibrosis is not a disease with spontaneous remissions, even non-randomized trials carry weight. In this survey, the existing evidence will be analysed, both for the commonly used treatments like erythropoiesis-stimulating agents, androgens and thalidomide and for the new drugs in the area, and conclusions will be drawn concerning standard clinical anaemia treatment in myelofibrosis, which according to evidence from studies has a 40-50% chance of response in patients with not too advanced disease.
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Tibes R, Mesa RA. Targeting hedgehog signaling in myelofibrosis and other hematologic malignancies. J Hematol Oncol 2014; 7:18. [PMID: 24598114 PMCID: PMC3975838 DOI: 10.1186/1756-8722-7-18] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 02/20/2014] [Indexed: 01/05/2023] Open
Abstract
Treatment of myelofibrosis (MF), a BCR-ABL-negative myeloproliferative neoplasm, is challenging. The only current potentially curative option, allogeneic hematopoietic stem cell transplant, is recommended for few patients. The remaining patients are treated with palliative therapies to manage MF-related anemia and splenomegaly. Identification of a mutation in the Janus kinase 2 (JAK2) gene (JAK2 V617F) in more than half of all patients with MF has prompted the discovery and clinical development of inhibitors that target JAK2. Although treatment with JAK2 inhibitors has been shown to improve symptom response and quality of life in patients with MF, these drugs do not alter the underlying disease; therefore, novel therapies are needed. The hedgehog (Hh) signaling pathway has been shown to play a role in normal hematopoiesis and in the tumorigenesis of hematologic malignancies. Moreover, inhibitors of the Hh pathway have been shown to inhibit growth and self-renewal capacity in preclinical models of MF. In a mouse model of MF, combined inhibition of the Hh and JAK pathways reduced JAK2 mutant allele burden, reduced bone marrow fibrosis, and reduced white blood cell and platelet counts. Preliminary clinical data also suggest that inhibition of the Hh pathway, alone or in combination with JAK2 inhibition, may enable disease modification in patients with MF. Future studies, including one combining the Hh pathway inhibitor sonidegib and the JAK2 inhibitor ruxolitinib, are underway in patients with MF and will inform whether this combination approach can lead to true disease modification.
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Affiliation(s)
- Raoul Tibes
- Mayo Clinic Cancer Center, NCI Designated Comprehensive Cancer Center, 13400 E. Shea Blvd, Scottsdale, AZ 85259, USA
| | - Ruben A Mesa
- Mayo Clinic Cancer Center, NCI Designated Comprehensive Cancer Center, 13400 E. Shea Blvd, Scottsdale, AZ 85259, USA
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45
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Koopmans SM, Schouten HC. Treatment options for myelofibrosis and myeloproliferative neoplasia. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Essential thrombocythemia, polycythemia vera and primary myelofibrosis belong to the Philadelphia chromosome negative (Ph-) myeloproliferative neoplasia (MPN) group of diseases. MPNs are clonal bone marrow stem cell disorders characterized by a proliferation of one or more of the myeloid, erythroid or megakaryocytic cell lines. The treatment of MPN patients should be carried out according to their risk stratification. In 2005 a mutation in the JAK2 gene was discovered that generated more insight into the pathogenetic working mechanism of MPNs. However, the treatment of MPN patients is still mainly only palliative, although progress is being made in reducing the symptoms for MPN patients. This review will give a general overview of the treatment of MPN patients.
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Affiliation(s)
- Suzanne M Koopmans
- Department of Internal Medicine of the University Hospital Maastricht, Postbus 5800, 6202 AZ Maastricht, The Netherlands
| | - Harry C Schouten
- Department of Internal Medicine of the University Hospital Maastricht, Postbus 5800, 6202 AZ Maastricht, The Netherlands
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46
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Keohane C, Radia DH, Harrison CN. Treatment and management of myelofibrosis in the era of JAK inhibitors. Biologics 2013; 7:189-98. [PMID: 23990704 PMCID: PMC3753053 DOI: 10.2147/btt.s34942] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Myelofibrosis (MF) can present as a primary disorder or evolve from polycythemia vera (PV) or essential thrombocythemia (ET) to post-PV MF or post-ET MF, respectively. MF is characterized by bone marrow fibrosis, splenomegaly, leukoerythroblastosis, extramedullary hematopoiesis, and a collection of debilitating symptoms. Until recently, the therapeutic options for patients with MF consisted of allogeneic hematopoietic stem cell transplant (alloHSCT), the use of cytoreductive agents (ie, hydroxyurea), splenectomy and splenic irradiation for treatment of splenomegaly, and management of anemia with transfusions, erythropoiesis-stimulating agents (ESAs), androgens, and immunomodulatory agents. However, with increased understanding of the pathogenesis of MF resulting from dysregulated Janus kinase (JAK) signaling, new targeted JAK inhibitor therapies, such as ruxolitinib, are now available. The purpose of this article is to review the clinical features of MF, discuss the use and future of JAK inhibitors, reassess when and how to use conventional MF treatments in the context of JAK inhibitors, and provide a perspective on the future of MF treatment.
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Affiliation(s)
- Clodagh Keohane
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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47
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A comprehensive review and analysis of the effect of ruxolitinib therapy on the survival of patients with myelofibrosis. Blood 2013; 121:4832-7. [DOI: 10.1182/blood-2013-02-482232] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Myelofibrosis is a hematological malignancy with a median survival of approximately 5 to 7 years. Allogeneic stem cell transplantation is the only therapeutic modality that provides a cure for myelofibrosis patients. Recently, ruxolitinib has been shown in 2 phase 3 studies to be effective in reducing splenomegaly and improving symptoms in myelofibrosis patients. Although conventional markers of disease burden (marrow histopathological features, cytogenetic and molecular markers, and reversal of cytopenias) were not uniformly improved, a survival advantage in favor of ruxolitinib therapy was demonstrated. The use of historical control cohorts to compare survival was implemented in 2 different analyses of patients enrolled in the phase 1/2 studies and has further added fuel to the controversy surrounding the significance of this survival advantage. Ruxolitinib therapy results in a dramatic reduction in circulating proinflammatory cytokine levels, which has been associated with improvement in symptoms and performance status and may provide a link to improved survival. We analyze the various data published and place in perspective the significance of the prolongation of survival associated with ruxolitinib therapy. This critical review of these data may allow physicians to more rationally assess the benefits that can be anticipated with the appropriate use of this therapy.
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48
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Palandri F, Polverelli N, Catani L, Cavo M, Vianelli N. Update on the treatment of Ph-negative myeloproliferative neoplasms. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
SUMMARY Myeloproliferative neoplasms (MPNs) that do not harbor the BCR–ABL rearrangement include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis. All of these diseases are characterized by an increased risk of vascular complications and by the propensity to evolve into acute leukemia. The JAK2V617F mutation determines a gain of function in the gene encoding JAK2 and is the most frequent molecular abnormality in MPNs, with an estimated prevalence of more than 95% in PV and 50% in ET and primary myelofibrosis. Molecular markers, together with marrow histology and cytogenetic data, are increasingly relevant for MPN diagnosis, and their prognostic value is under evaluation. In PV and ET, the use of aspirin, hydroxyurea and phlebotomy remain the mainstay of treatment. In myelofibrosis, conventional therapy (androgens, steroids, chemotherapy and splenectomy) has still only palliative effects. The only potentially curative approach is allogeneic stem cell transplantation, but treatment-related mortality remains high. In the last 2 years, the JAK–STAT pathway has become the target of selective tyrosine kinase inhibitors, which might represent a promising therapeutic option. Their role in future therapy, as single agents and/or in combinatorial approaches, is yet to be determined.
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Affiliation(s)
- Francesca Palandri
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy.
| | - Nicola Polverelli
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Lucia Catani
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Michele Cavo
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Nicola Vianelli
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
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Cervantes F, Martinez-Trillos A. Myelofibrosis: an update on current pharmacotherapy and future directions. Expert Opin Pharmacother 2013; 14:873-84. [PMID: 23514013 DOI: 10.1517/14656566.2013.783019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Myelofibrosis (MF) is a myeloproliferative neoplasm characterized by symptoms mainly derived from anemia and splenomegaly and constitutional symptoms and associated with a median survival around 6 years. Allogeneic stem cell transplantation (allo-SCT) remains the only curative therapy of MF but is applicable to a minority of patients. Discovery of the JAK2 mutation has provided the basis for the introduction of a new class of drugs, the JAK inhibitors, in the treatment of MF. AREAS COVERED A literature review on the therapy of MF has been performed through a PubMed search, with special attention being paid to the available data on transplantation, the JAK inhibitors, and other new drugs. EXPERT OPINION Conventional therapy of MF is usually adjusted to the predominant clinical symptoms in each patient, and its impact on survival is limited. Reduced-intensity conditioning regimens have increased the number of patients eligible for allo-SCT, but this procedure is still associated with substantial morbidity and mortality. The JAK inhibitors, such as ruxolitinib, can achieve profound symptomatic relief of the splenomegaly and the constitutional symptoms. However, they often accentuate the anemia and do not reduce the JAK2 allele burden, therefore lacking the potential to modify the natural history of MF.
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Affiliation(s)
- Francisco Cervantes
- University of Barcelona, Hospital Clínic, Hematology Department, IDIBAPS, Villarroel 170, 08036 Barcelona, Spain.
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50
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Abstract
Myelofibrosis (MF) is a BCR-ABL1-negative myeloproliferative neoplasm diagnosed de novo or developed from essential thrombocythemia (ET) or polycythemia vera (PV). Average survival of a patient with MF is 5-7 years. Disease complications include fatigue, early satiety, pruritus, painful splenic infarcts, infections and leukemic transformation. Allogeneic hematopoietic stem cell transplant (HSCT) is the only potentially curative option for MF, but carries a risk of treatment-related mortality and is reserved for the few high-risk patients fit enough to endure the procedure. Other traditional therapies are palliative and supported by few randomized, controlled trials; thus, novel treatment strategies are needed. Discovery of the Janus kinase 2 (JAK2) gain-of-function mutation, JAK2V617F, in the majority (50-60%) of patients with MF led to increased understanding of the biology underlying MF and the development of JAK2 inhibitors to treat MF. Recent Food and Drug Administration (FDA) approval of the first JAK2 inhibitor, ruxolitinib, signaled a new era for treatment of MF. Additional JAK2 inhibitors, such as SAR302503, may become commercially available in the near future, and their distinct pharmacologic and efficacy profiles will help determine their use across the patient population. Data on JAK2 inhibitors, their role in an evolving treatment paradigm, and future directions for treatment of MF are discussed.
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Affiliation(s)
- Ruben A Mesa
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, AZ 85259, USA.
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