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Jung EH, Hong J, Kim SY, Park Y, Yuh YJ, Mun YC, Lee WS, Park SK, Bang SM. Real-World Outcomes of Ruxolitinib in Patients With Myelofibrosis Focusing on Red Blood Cell Transfusion: A Multicenter Study From the MPN Working Party of the Korean Society of Hematology. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e931-e937. [PMID: 35858905 DOI: 10.1016/j.clml.2022.06.008] [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: 06/07/2022] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION/BACKGROUND Ruxolitinib is an established treatment for myelofibrosis (MF) that has demonstrated clinical benefit by reducing spleen size and debilitating MF-related symptoms. However, despite the efficacy of ruxolitinib, anemia remains a major adverse event that causes dose modification or discontinuation in real-world practice. Additionally, dependence on red blood cell (RBC) transfusion (TF) is common during treatment; therefore, we explored the outcome of ruxolitinib therapy with a primary focus on RBC TF. PATIENTS/METHODS We retrospectively reviewed the medical records of 123 MF patients treated with ruxolitinib between January 2012 and April 2020 at eight academic centers in Korea. RESULTS At ruxolitinib initiation, 38 patients (30.9%) underwent ≥ 2 units of RBC TF over 8 weeks. The most common reason for permanent discontinuation was intolerant anemia (10/63, 15.9%). The most common reasons for temporary interruption were nonhematologic toxicity (26/55, 21.1%), anemia (23/55, 18.7%) and thrombocytopenia (13/55, 10.6%). Among the 123 patients in the study, 57 (46.3%), 42 (34.1%), and 40 patients (32.5%) who were receiving or stopped ruxolitinib therapy had a status of RBC TF dependence, long-term RBC TF dependence, or severe RBC TF dependence, respectively. The presence of ≥ 2 units of RBC transfusion over 8 weeks at ruxolitinib initiation was an independent risk factor for persistent RBC TF dependence. CONCLUSION The requirement for RBC TF is commonly encountered during treatment of MF with ruxolitinib, particularly among those with pre-existing ≥ 2 units of RBC TF over 8 weeks. For those patients, overcoming the barrier of maintenance TF is demanding.
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Affiliation(s)
- Eun Hee Jung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Sung-Yong Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Young Park
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Young Jin Yuh
- Division of Hematology-Oncology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Yeung-Chul Mun
- Department of Hematology-Oncology, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Won-Sik Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Sung-Kyu Park
- Division of Hematology & Oncology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Soo Mee Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Harrison CN, Gupta VK, Gerds AT, Rampal R, Verstovsek S, Talpaz M, Kiladjian JJ, Mesa R, Kuykendall AT, Vannucchi AM, Palandri F, Grosicki S, Devos T, Jourdan E, Wondergem MJ, Al-Ali HK, Buxhofer-Ausch V, Alvarez-Larrán A, Patriarca A, Kremyanskaya M, Mead AJ, Akhani S, Sheikine Y, Colak G, Mascarenhas J. Phase III MANIFEST-2: pelabresib + ruxolitinib vs placebo + ruxolitinib in JAK inhibitor treatment-naive myelofibrosis. Future Oncol 2022; 18:2987-2997. [PMID: 35950489 DOI: 10.2217/fon-2022-0484] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Myelofibrosis (MF) is a clonal myeloproliferative neoplasm, typically associated with disease-related symptoms, splenomegaly, cytopenias and bone marrow fibrosis. Patients experience a significant symptom burden and a reduced life expectancy. Patients with MF receive ruxolitinib as the current standard of care, but the depth and durability of responses and the percentage of patients achieving clinical outcome measures are limited; thus, a significant unmet medical need exists. Pelabresib is an investigational small-molecule bromodomain and extraterminal domain inhibitor currently in clinical development for MF. The aim of this article is to describe the design of the ongoing, global, phase III, double-blind, placebo-controlled MANIFEST-2 study evaluating the efficacy and safety of pelabresib and ruxolitinib versus placebo and ruxolitinib in patients with JAKi treatment-naive MF. Clinical Trial Registration: NCT04603495 (ClinicalTrials.gov).
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Affiliation(s)
- Claire N Harrison
- Guys & St Thomas' NHS Foundation Trust, Guy's Hospital, London, SE1 9RT, UK
| | - Vikas K Gupta
- Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, M5G 1Z5, Canada
| | - Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA
| | - Raajit Rampal
- Leukemia Service, Department of Medicine and Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Moshe Talpaz
- Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI 48109-5936, USA
| | - Jean-Jacques Kiladjian
- Clinical Investigation Center (INSERM CIC 1427), Université Paris Cité and Hôpital Saint-Louis, Paris, 75010, France
| | - Ruben Mesa
- Mays Cancer Center, UT Health San Antonio Cancer Center, San Antonio, TX 78229-3900, USA
| | - Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Alessandro M Vannucchi
- Department of Hematology, Azienda Ospedaliero-Universitaria Careggi, Firenze, 50139, Italy
| | - Francesca Palandri
- Department of Hematology, IRCCS Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, 40138, Italy
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia in Katowice, Katowice, 40-055, Poland
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven & Laboratory of Molecular Immunology (Rega Institute), KU Leuven, Leuven, 3000, Belgium
| | - Eric Jourdan
- Department of Hematology, C.H.U., Nîmes, 30029, France
| | - Marielle J Wondergem
- Department of Hematology, Amsterdam University Medical Centers, Amsterdam, 1081 HV, The Netherlands
| | | | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I with Hematology, Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz Elisabethinen & Johannes Kepler University Linz, Linz, 4020, Austria
| | | | - Andrea Patriarca
- Hematology Unit, Azienda Ospedaliero Universitaria Maggiore della Carità di Novara, Novara, 28100, Italy
| | - Marina Kremyanskaya
- Division of Hematology and Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Adam J Mead
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DX, UK
| | | | - Yuri Sheikine
- Constellation Pharmaceuticals, Inc., a MorphoSys Company, Boston, MA 02110, USA
| | - Gozde Colak
- Constellation Pharmaceuticals, Inc., a MorphoSys Company, Boston, MA 02110, USA
| | - John Mascarenhas
- Division of Hematology and Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Harrison CN, Schaap N, Vannucchi AM, Kiladjian JJ, Passamonti F, Zweegman S, Talpaz M, Verstovsek S, Rose S, Zhang J, Sy O, Mesa RA. Safety and efficacy of fedratinib, a selective oral inhibitor of Janus kinase-2 (JAK2), in patients with myelofibrosis and low pretreatment platelet counts. Br J Haematol 2022; 198:317-327. [PMID: 35476316 PMCID: PMC9541243 DOI: 10.1111/bjh.18207] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/01/2022] [Accepted: 04/06/2022] [Indexed: 02/06/2023]
Abstract
Fedratinib, an oral Janus kinase‐2 (JAK2) inhibitor, is approved for patients with myelofibrosis (MF) and platelet counts ≥50 × 109/l, based on outcomes from the phase 3, placebo‐controlled JAKARTA trial in JAK‐inhibitor‐naïve MF, and the phase 2, single‐arm JAKARTA2 trial in patients previously treated with ruxolitinib. We evaluated the efficacy and safety of fedratinib 400 mg/day in patients with baseline platelet counts 50 to <100 × 109/l (“Low‐Platelets” cohorts), including 14/96 patients (15%) in JAKARTA and 33/97 (34%) in JAKARTA2. At 24 weeks, spleen response rates were not significantly different between the Low‐Platelets cohort and patients with baseline platelet counts ≥100 × 109/l (“High‐Platelets” cohort), in JAKARTA (36% vs. 49%, respectively; p = 0.37) or JAKARTA2 (36% vs. 28%; p = 0.41). Symptom response rates were also not statistically different between the Low‐ and High‐Platelets cohorts. Fedratinib was generally well‐tolerated in both platelet‐count cohorts. New or worsening thrombocytopaenia was more frequent in the Low‐Platelets (44%) versus the High‐Platelets (9%) cohort, but no serious thrombocytopaenia events occurred. Thrombocytopaenia was typically managed with dose modifications; only 3/48 Low‐Platelets patients discontinued fedratinib due to thrombocytopaenia. These data indicate that fedratinib 400 mg/day is safe and effective in patients with MF and low pretreatment platelet counts, and no initial fedratinib dose adjustment is required for these patients.
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Affiliation(s)
- Claire N Harrison
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicolaas Schaap
- Radboud University Medical Centre Nijmegen, Nijmegen, Netherlands
| | - Alessandro M Vannucchi
- Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence, Florence, Italy
| | - Jean-Jacques Kiladjian
- Centre d'Investigations Cliniques, INSERM, CIC1427, AP-HP, Hôpital Saint-Louis, Université de Paris, Paris, France
| | | | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Moshe Talpaz
- University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA
| | - Srdan Verstovsek
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Jun Zhang
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Oumar Sy
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Ruben A Mesa
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, Texas, USA
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Abstract
Background This study analyses treatment patterns, health care resource utilization (HCRU), and costs in patients with myelofibrosis (MF) and a subgroup treated with ruxolitinib (RUX). Materials and Methods Treatment patterns, all-cause and MF-related HCRU, and costs were analyzed in adults with MF with continuous enrollment in a commercial or the Medicare Advantage health plan in the pre-index period, defined as the 12 months immediately prior to the index date (date of primary or secondary MF diagnosis), and the post-index period, defined as ≥6 months following the index date. In a subgroup analysis, outcomes were analyzed in patients treated with optimal RUX (OPT RUX, ≥30 mg) and suboptimal RUX (SUB RUX, <30 mg) in the pre-index RUX period, defined as the 3 months immediately prior to the index RUX date (first date for an RUX claim), and the post-index RUX period, defined as ≥6 months following the index RUX date. Results Of 2830 patients with an MF diagnosis, 1191 met eligibility requirements. The median age of patients was 72 years, 54% were male, and comorbidities were frequent. Sixty percent of patients received ≥1 line of therapy (LOT), of which 46% (n = 331) had ≥2 LOTs during the post-index MF period. Costs increased considerably 6-month pre-index to 6-month post-index (all-cause: cause ($24,216 to $48,966) and MF-related ($16,502 to $39,383), driven by inpatient stays and pharmacy costs. In the subgroup analysis, patients treated with RUX (n = 495) experienced significant disease burden and high costs, regardless of dose. A shorter duration of therapy and a higher rate of discontinuation were observed in patients treated with SUB RUX (n = 191) versus OPT RUX (n = 304). Conclusion These findings suggest a significant disease and economic impacts associated with MF patients that persists with RUX therapy, highlighting the need for additional therapeutic options for MF.
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Affiliation(s)
- Ronda Copher
- Corresponding author: Ronda Copher WW HEOR, US Hematology, Bristol-Myers Squibb, 100 Nassau Park Boulevard #300, Princeton, NJ 08540, USA; Tel:+1 908 673 9594;
| | | | - Aaron Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
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5
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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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6
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Pandravada S, Sandler S. The Role of Navitoclax in Myelofibrosis. Cureus 2021; 13:e17976. [PMID: 34667663 PMCID: PMC8516617 DOI: 10.7759/cureus.17976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 11/05/2022] Open
Abstract
Primary myelofibrosis (PMF) is the most aggressive type of chronic myeloproliferative neoplasm, characterized by a disarray of hematopoietic stem cells and bone marrow fibrosis. The estimated incidence is 1.5 per 100,000 individuals per year with a median survival of less than six years. This statistic can vary by risk category, primarily based on clinical and cytogenetic features. Death can result from many causes, including leukemic transformation, cachexia, vascular events, and infection. Currently, allogeneic hematopoietic cell transplant is the only curative method for those at high risk. Unfortunately, only about 10% are eligible for this therapy. JAK2 kinase inhibitors are commonly used for high-risk patients with symptomatic splenomegaly or systemic symptoms from PMF. In clinical trials, the major endpoint is a reduction of spleen size by 35%. Secondary endpoints have included amelioration of symptomatic PMF and overall survival, which can be difficult to determine because of frequent co-morbid conditions. Current Food and Drug Administration (FDA)-approved JAK2 inhibitors have not shown increased survival or reduced risk of leukemic transformation. In relapsed or refractory disease, there is currently no standard of care. In this paper, we discuss the role of a new anti-apoptotic B cell leukemia 2 (Bcl-2) inhibitor, Navitoclax, for the treatment of myelofibrosis. The clinical data thus far for Navitoclax, especially in synergistic combination with traditional JAK2 inhibitors, have been promising for those with a refractory or relapsing disease on prior therapies. Following the encouraging results of phase II trials, ongoing phase III trials will primarily evaluate splenic size reduction versus the standard of care and evaluate secondary endpoints such as symptom reduction and overall survival. These studies may establish a new standard of care for refractory or relapsed myelofibrosis.
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Affiliation(s)
| | - Steven Sandler
- Hematology/Oncology, NorthShore University HealthSystem, Skokie, USA
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7
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Passamonti F, Gupta V, Martino B, Foltz L, Zaritskey A, Al-Ali HK, Tavares R, Maffioli M, Raanani P, Giraldo P, Griesshammer M, Guglielmelli P, Bouard C, Paley C, Tiwari R, Vannucchi AM. Comparing the safety and efficacy of ruxolitinib in patients with Dynamic International Prognostic Scoring System low-, intermediate-1-, intermediate-2-, and high-risk myelofibrosis in JUMP, a Phase 3b, expanded-access study. Hematol Oncol 2021; 39:558-566. [PMID: 34224180 PMCID: PMC8518822 DOI: 10.1002/hon.2898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/05/2021] [Accepted: 06/24/2021] [Indexed: 01/05/2023]
Abstract
Ruxolitinib, a potent Janus kinase 1/2 inhibitor, has demonstrated durable improvements in patients with myelofibrosis. In this analysis of the Phase 3b JUMP study, which included patients aged ≥18 years with a diagnosis of primary or secondary myelofibrosis, we assessed the safety and efficacy of ruxolitinib in patients stratified by Dynamic International Prognostic Scoring System (DIPSS) risk categories. Baseline characteristic data were available to assess DIPSS status for 1844 of the 2233 enrolled patients; 60, 835, 755, and 194 in the low‐, intermediate (Int)‐1‐, Int‐2‐, and high‐risk groups, respectively. Ruxolitinib was generally well tolerated across all risk groups, with an adverse‐event (AE) profile consistent with previous reports. The most common hematologic AEs were thrombocytopenia and anemia, with highest rates of Grade ≥3 events in high‐risk patients. Approximately, 73% of patients experienced ≥50% reductions in palpable spleen length at any point in the ≤24‐month treatment period, with highest rates in lower‐risk categories (low, 82.1%; Int‐1, 79.3%; Int‐2, 67.1%; high risk, 61.6%). Median time to spleen length reduction was 5.1 weeks and was shortest in lower‐risk patients. Across measures, 40%–57% of patients showed clinically meaningful symptom improvements, which were observed from 4 weeks after treatment initiation and maintained throughout the study. Overall survival (OS) was 92% at Week 72 and 75% at Week 240 (4.6 years). Median OS was longer for Int‐2‐risk than high‐risk patients (253.6 vs. 147.3 weeks), but not evaluable in low‐/Int‐1‐risk patients. By Week 240, progression‐free survival (PFS) and leukemia‐free survival (LFS) rates were higher in lower‐risk patients (PFS: low, 90%; Int‐1, 82%; Int‐2, 46%; high risk, 15%; LFS: low, 92%; Int‐1, 86%; Int‐2, 58%; high risk, 19%). Clinical benefit was seen across risk groups, with more rapid improvements in lower risk patients. Overall, this analysis indicates that ruxolitinib benefits lower‐risk DIPSS patients in addition to higher risk.
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Affiliation(s)
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Bruno Martino
- Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Lynda Foltz
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Andrey Zaritskey
- Federal Almazov Medical Research Center of the Russian Ministry of Health, St Petersburg, Russia
| | | | | | | | - Pia Raanani
- Rabin Medical Center, Petah Tikva and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pilar Giraldo
- Miguel Servet University Hospital and Centro de Investigacion Biomedica en Red de Enfermedades Raras (CIBERER), Zaragoza, Spain
| | | | - Paola Guglielmelli
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence, Florence, Italy
| | | | | | - Ranjan Tiwari
- Novartis Healthcare Pvt., Ltd., Hyderabad, Telangana, India
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence, Florence, Italy
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8
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Cohen P, Cross D, Jänne PA. Kinase drug discovery 20 years after imatinib: progress and future directions. Nat Rev Drug Discov 2021; 20:551-569. [PMID: 34002056 PMCID: PMC8127496 DOI: 10.1038/s41573-021-00195-4] [Citation(s) in RCA: 467] [Impact Index Per Article: 155.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 02/04/2023]
Abstract
Protein kinases regulate nearly all aspects of cell life, and alterations in their expression, or mutations in their genes, cause cancer and other diseases. Here, we review the remarkable progress made over the past 20 years in improving the potency and specificity of small-molecule inhibitors of protein and lipid kinases, resulting in the approval of more than 70 new drugs since imatinib was approved in 2001. These compounds have had a significant impact on the way in which we now treat cancers and non-cancerous conditions. We discuss how the challenge of drug resistance to kinase inhibitors is being met and the future of kinase drug discovery.
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Affiliation(s)
- Philip Cohen
- MRC Protein Phosphorylation and Ubiquitylation Unit, School of Life Sciences, University of Dundee, Dundee, UK.
| | | | - Pasi A Jänne
- Lowe Center for Thoracic Oncology, Dana Farber Cancer Institute, Harvard University, Boston, MA, USA.
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Gill H, Leung GMK, Yim R, Lee P, Pang HH, Ip HW, Leung RYY, Li J, Panagiotou G, Ma ESK, Kwong YL. Myeloproliferative neoplasms treated with hydroxyurea, pegylated interferon alpha-2A or ruxolitinib: clinicohematologic responses, quality-of-life changes and safety in the real-world setting. ACTA ACUST UNITED AC 2020; 25:247-257. [PMID: 32567517 DOI: 10.1080/16078454.2020.1780755] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Real-world data of responses, quality-of-life (QOL) changes and adverse events in patients with myeloproliferative neoplasms (MPN) on conventional therapy (hydroxyurea ± anagrelide), pegylated interferon alpha-2A (PEG-IFNα-2A) or ruxolitinib are limited. Methods: We prospectively studied MPN patients receiving conventional therapy, PEG-IFNα-2A or ruxolitinib. Next-generation sequencing of 69 myeloid-related genes was performed. Clinicohematologic responses, adverse events, and QOL (determined by the Myeloproliferative Neoplasm Symptom Assessment Form Total Symptom Score, MPN-SAF TSS) were evaluated. Results: Seventy men and fifty-five women with polycythemia vera (PV) (N = 23), essential thrombocythemia (ET) (N = 56) and myelofibrosis (MF) (N = 46) were studied for a median of 36 (range: 19-42) months. In PV, responses were comparable for different modalities. CREBBP mutations were associated with inferior responses. In ET, PEG-IFNα-2A resulted in superior clinicohematologic complete responses (CHCR) (P = 0.045). In MF, superior overall response rates (ORR) were associated with ruxolintib (P = 0.018) and JAK2V617F mutation (P = 0.04). For the whole cohort, ruxolitinib led to rapid and sustained reduction in spleen size within the first 6 months, and significant improvement of QOL as reflected by reduction in MPN-SAF TSS (P < 0.001). Adverse events of grades 1-2 were observed in 44%, 62% and 20% of patients receiving conventional therapy, PEG-IFNα-2A and ruxolitinib respectively; and of grade 3-4 in 7% and 9% of patients receiving PEG-IFNα-2A and ruxolitinib. Conclusions: Conventional therapy, PEG-IFNα-2A and ruxolitinib induced responses in all MPN subtypes. PEG-IFNα-2A led to superior CHCR in ET; whereas ruxolitinib resulted in superior ORR in MF, and significant reduction in spleen size and improvement in QOL.
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Affiliation(s)
- Harinder Gill
- Department of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Garret M K Leung
- Department of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Rita Yim
- Department of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Paul Lee
- Department of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Herbert H Pang
- School of Public Health, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Ho-Wan Ip
- Department of Pathology, Queen Mary Hospital, Hong Kong, People's Republic of China
| | - Rock Y Y Leung
- Department of Pathology, Queen Mary Hospital, Hong Kong, People's Republic of China
| | - Jun Li
- Department of Infectious Diseases and Public Health, The City University of Hong Kong, Hong Kong, People's Republic of China.,School of Biological Sciences, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Gianni Panagiotou
- School of Biological Sciences, The University of Hong Kong, Hong Kong, People's Republic of China.,Department of Microbiology, The University of Hong Kong, Hong Kong, People's Republic of China.,Department of Systems Biology and Bioinformatics, Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute (HKI), Jena, Germany
| | - Edmond S K Ma
- Department of Pathology, Hong Kong Sanatorium and Hospital, Hong Kong, People's Republic of China
| | - Yok-Lam Kwong
- Department of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China
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10
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Hopkins AM, Menz BD, Wiese MD, Kichenadasse G, Gurney H, McKinnon RA, Rowland A, Sorich MJ. Nuances to precision dosing strategies of targeted cancer medicines. Pharmacol Res Perspect 2020; 8:e00625. [PMID: 32662214 PMCID: PMC7358594 DOI: 10.1002/prp2.625] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/22/2020] [Accepted: 06/22/2020] [Indexed: 01/05/2023] Open
Abstract
Selecting the dose of a targeted cancer medicine that is most appropriate for a specific individual is a rational approach to maximize therapeutic outcomes and minimize toxicity. There are many different options for optimizing the dose of targeted cancer medicines and the purpose of this review is to provide a comprehensive comparison of the main options explored in prospective studies. Precision initial dose selection of targeted cancer therapies has been minimally explored to date; however, concentration, toxicity, and therapeutic outcome markers are used to guide on-therapy dose adaption of targeted cancer therapies across several medicines and cancers. While a specific concentration, toxicity, or therapeutic outcome marker commonly dominates an investigated precision on-therapy dose adaption strategy, greater attention to simultaneously account for exposure, toxicity, therapeutic outcomes, disease status, time since treatment initiation and patient preferences are required for optimal patient outcomes. To enable successful implementation of precision dosing strategies for targeted cancer medicines into clinical practice, future prospective studies aiming to develop strategies should consider these elements in their design.
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Affiliation(s)
- Ashley M. Hopkins
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Bradley D. Menz
- Division of PharmacySouthern Adelaide Local Health Network, Flinders Medical CentreAdelaideSouth AustraliaAustralia
| | - Michael D. Wiese
- School of Pharmacy and Medical SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Ganessan Kichenadasse
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Howard Gurney
- Department of Medical OncologyWestmead HospitalSydneyNew South WalesAustralia
| | - Ross A. McKinnon
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Andrew Rowland
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Michael J. Sorich
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
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Fedratinib, a newly approved treatment for patients with myeloproliferative neoplasm-associated myelofibrosis. Leukemia 2020; 35:1-17. [PMID: 32647323 PMCID: PMC7787977 DOI: 10.1038/s41375-020-0954-2] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/15/2020] [Accepted: 06/25/2020] [Indexed: 01/04/2023]
Abstract
Myeloproliferative neoplasm (MPN)-associated myelofibrosis (MF) is characterized by cytopenias, marrow fibrosis, constitutional symptoms, extramedullary hematopoiesis, splenomegaly, and shortened survival. Constitutive activation of the janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling pathway in MF leads to cell proliferation, inhibition of cell death, and clonal expansion of myeloproliferative malignant cells. Fedratinib is a selective oral JAK2 inhibitor recently approved in the United States for treatment of adult patients with intermediate-2 or high-risk MF. In mouse models of JAK2V617F-driven myeloproliferative disease, fedratinib blocked phosphorylation of STAT5, increased survival, and improved MF-associated disease features, including reduction of white blood cell counts, hematocrit, splenomegaly, and fibrosis. Fedratinib exerts off-target inhibitory activity against bromodomain-containing protein 4 (BRD4); combination JAK/STAT and BRD4 inhibition was shown to synergistically block NF-kB hyperactivation and inflammatory cytokine production, attenuating disease burden and reversing bone marrow fibrosis in animal models of MPNs. In patients, fedratinib is rapidly absorbed and dosed once daily (effective half-life 41 h). Fedratinib showed robust clinical activity in JAK-inhibitor-naïve patients and in patients with MF who were relapsed, refractory, or intolerant to prior ruxolitinib therapy. Fedratinib is effective regardless of JAK2 mutation status. Onset of spleen and symptom responses are typically seen within the first 1–2 months of treatment. The most common adverse events (AEs) with fedratinib are grades 1–2 gastrointestinal events, which are most frequent during early treatment and decrease over time. Treatment discontinuation due to hematologic AEs in clinical trials was uncommon (~3%). Suspected cases of Wernicke’s encephalopathy were reported during fedratinib trials in ~1% of patients; thiamine levels should be monitored before and during fedratinib treatment as medically indicated. Phase III trials are ongoing to assess fedratinib effects on long-term safety, efficacy, and overall survival. The recent approval of fedratinib provides a much-needed addition to the limited therapeutic options available for patients with MF.
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Harrison CN, Schaap N, Mesa RA. Management of myelofibrosis after ruxolitinib failure. Ann Hematol 2020; 99:1177-1191. [PMID: 32198525 PMCID: PMC7237516 DOI: 10.1007/s00277-020-04002-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 12/20/2022]
Abstract
Myelofibrosis is a BCR-ABL1-negative myeloproliferative neoplasm characterized by anemia, progressive splenomegaly, extramedullary hematopoiesis, bone marrow fibrosis, constitutional symptoms, leukemic progression, and shortened survival. Constitutive activation of the Janus kinase/signal transducers and activators of transcription (JAK-STAT) pathway, and other cellular pathways downstream, leads to myeloproliferation, proinflammatory cytokine expression, and bone marrow remodeling. Transplant is the only curative option for myelofibrosis, but high rates of morbidity and mortality limit eligibility. Several prognostic models have been developed to facilitate treatment decisions. Until the recent approval of fedratinib, a JAK2 inhibitor, ruxolitinib was the only available JAK inhibitor for treatment of intermediate- or high-risk myelofibrosis. Ruxolitinib reduces splenomegaly to some degree in almost all treated patients; however, many patients cannot tolerate ruxolitinib due to dose-dependent drug-related cytopenias, and even patients with a good initial response often develop resistance to ruxolitinib after 2-3 years of therapy. Currently, there is no consensus definition of ruxolitinib failure. Until fedratinib approval, strategies to overcome ruxolitinib resistance or intolerance were mainly different approaches to continued ruxolitinib therapy, including dosing modifications and ruxolitinib rechallenge. Fedratinib and two other JAK2 inhibitors in later stages of clinical development, pacritinib and momelotinib, have been shown to induce clinical responses and improve symptoms in patients previously treated with ruxolitinib. Fedratinib induces robust spleen responses, and pacritinib and momelotinib may have preferential activity in patients with severe cytopenias. Reviewed here are strategies to ameliorate ruxolitinib resistance or intolerance, and outcomes of clinical trials in patients with myelofibrosis receiving second-line JAK inhibitors after ruxolitinib treatment.
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Affiliation(s)
- Claire N Harrison
- Guy's and St Thomas' Hospital Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK.
| | | | - Ruben A Mesa
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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13
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Abstract
Over the last decade, the Janus kinase1/2 (JAK1/2) inhibitor ruxolitinib has emerged as a cornerstone of myelofibrosis (MF) management. Ruxolitinib improves splenomegaly and symptoms regardless of driver mutation status, and confers a survival advantage in patients with intermediate-2/high risk MF. However, cytopenias remain problematic, and evidence for a robust anti-clonal effect is lacking. Furthermore, the median duration of spleen response to ruxolitinib in clinical trials is approximately 3 years, and ruxolitinib does not appear to affect the risk of leukemic transformation. There is no therapy approved specifically for patients whose disease 'progresses' on ruxolitinib, defining which remains challenging. The recent regulatory approval of the JAK2 inihibitor fedratinib partially fulfills this unmet need, but much remains to be done. Other JAK inhibitors and a plethora of novel agents are being studied in the ruxolitinib 'failure' setting, as well as 'add-on' therapies to ruxolitinib in patients having a 'sub-optimal' response.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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14
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Benevolo G, Elli EM, Guglielmelli P, Ricco A, Maffioli M. Thrombocytopenia in patients with myelofibrosis: management options in the era of JAK inhibitor therapy. Leuk Lymphoma 2020; 61:1535-1547. [PMID: 32093511 DOI: 10.1080/10428194.2020.1728752] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Myelofibrosis (MF), either appearing de novo (primary MF, PMF) or after a previous diagnosis of essential thrombocythemia or of polycythemia vera, is a progressive disease burdened by symptomatic splenomegaly, debilitating systemic symptoms, ineffective hematopoiesis, and overall reduced survival. Patients often present worsening cytopenias, including thrombocytopenia, secondary to progression of the disease as well as to cytoreductive treatment. Patients with MF and thrombocytopenia have few therapeutic options and there is limited information regarding the management of disease in these settings. This article reviews current evidence for the management of patients with MF and thrombocytopenia, in the era of JAK inhibitors.
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Affiliation(s)
- Giulia Benevolo
- Hematology, AOU Città della Salute e della Scienza, Turin, Italy
| | - Elena M Elli
- Hematology Division and Bone Marrow Unit, San Gerardo Hospital, Monza, Italy
| | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Department of Experimental and Clinical Medicine, Azienda ospedaliera-Universitaria Careggi, University of Florence, Florence, Italy
| | - Alessandra Ricco
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari, Italy
| | - Margherita Maffioli
- Hematology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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15
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Li B, Rampal RK, Xiao Z. Targeted therapies for myeloproliferative neoplasms. Biomark Res 2019; 7:15. [PMID: 31346467 PMCID: PMC6636147 DOI: 10.1186/s40364-019-0166-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 07/10/2019] [Indexed: 01/02/2023] Open
Abstract
The discovery of JAK2V617F and the demonstration that BCR-ABL-negative myeloproliferative neoplasms (MPNs) are driven by abnormal JAK2 activation have led to advances in diagnostic algorithms, prognosis and ultimately also treatment strategies. The JAK 1/2 inhibitor ruxolitinib was a pivotal moment in the treatment of MPNs, representing the first targeted treatment in this field. Despite a weak effect on the cause of the disease itself in MPNs, ruxolitinib improves the clinical state of patients and increases survival in myelofibrosis. In parallel, other JAK inhibitors with potential for pathologic and molecular remissions, less myelosuppression, and with greater selectivity for JAK1 or JAK2, and the ability to overcome JAK inhibitor persistence are in various stages of development. Moreover, many novel classes of targeted agents continue to be investigated in efforts to build on the progress made with ruxolitinib. This article will discuss some of the advances in the targeted therapy in this field in recent years and explore in greater detail some of the most advanced emerging agents as well as those with greatest potential.
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Affiliation(s)
- Bing Li
- 1MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Tianjin, 300020 China.,2State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Raajit K Rampal
- 3Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Zhijian Xiao
- 1MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 288 Nanjing Road, Tianjin, 300020 China.,2State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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16
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SOHO State of the Art Updates and Next Questions: Myelofibrosis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:191-199. [PMID: 30987952 DOI: 10.1016/j.clml.2019.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/12/2019] [Indexed: 01/09/2023]
Abstract
The discovery of a mutation in the Janus Kinase 2 gene in 2005 spurred significant progress in the field of myeloproliferative neoplasms. A comprehensive description of genomic factors at play in the malignant clone in myeloproliferative neoplasms, particularly myelofibrosis (MF), have recently led to more precise, personalized prognostic tools. Despite this, understanding of the disease pathogenesis remains relatively limited. We continue to lack a detailed description of the interaction between the hematopoietic stem cell clone, abnormal bone marrow niche cells, and circulating signaling molecules and an understanding of how they cooperate to promote cell proliferation, fibrogenesis, and extramedullary hematopoiesis. Despite our knowledge gaps, recent research in MF has led to promising clinical translation. In this article, we summarize recent insights into MF pathophysiology, progress in the development of novel therapeutics, and opportunities for further advancement of the field.
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