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Sheel A, Bae J, Asada A, Otterson GA, Baliga RR, Koenig KL. Reversible cardiomyopathy in a patient with chronic myelomonocytic leukemia treated with decitabine/cedazuridine: a case report. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:4. [PMID: 36653885 PMCID: PMC9845814 DOI: 10.1186/s40959-023-00153-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hypomethylating agents (HMAs) have shown efficacy in the treatment of hematological malignancies and are indicated for the treatment of chronic myelomonocytic leukemia (CMML). While the HMA decitabine, in its intravenous formulation, has been used since 2006 for the treatment of CMML, use of its oral formulation has been limited by poor bioavailability due to first-pass metabolism by the enzyme cytidine deaminase. The dose of intravenous decitabine is limited by toxicities such as cardiomyopathy and heart failure. Therefore, cedazuridine was developed as an inhibitor of cytidine deaminase. Cedazuridine decreases the first-pass metabolism of oral decitabine allowing therapeutic levels to be achieved at lower doses, and thus, the novel oral combination of cedazuridine with decitabine was developed. While cardiomyopathy and heart failure are well-established adverse effects associated with intravenous decitabine alone, there to our knowledge there have been no documented incidences of reversible cardiomyopathy in the literature or in patients who participated in the phase 2 and phase 3 clinical trials of oral decitabine-cedazuridine. CASE This case study presents an 85 year-old Caucasian female with CMML who developed cardiomyopathy and heart failure with reduced ejection fraction after completing 5 cycles of therapy with decitabine/cedazuridine. Furthermore, her symptoms and cardiac function recovered upon discontinuation of the drug. CONCLUSIONS We present an occurrence of reversible cardiomyopathy in a patient who completed 5 cycles of decitabine/cedazuridine, an oral combination therapy developed to enhance oral bioavailability of decitabine thereby limiting its adverse effects. As the decitabine/cedazuridine combination therapy rises in popularity due to its convenient oral formulation, more trials are needed to understand the prevalence of cardiomyopathy with this drug and to discover preventative strategies for cardiotoxic effects.
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Affiliation(s)
- Ankur Sheel
- grid.412332.50000 0001 1545 0811Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210 USA
| | - Junu Bae
- grid.261331.40000 0001 2285 7943College of Medicine, The Ohio State University, Columbus, OH 43210 USA
| | - Ashlee Asada
- grid.412332.50000 0001 1545 0811Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210 USA
| | - Gregory A. Otterson
- grid.413944.f0000 0001 0447 4797Division of Oncology, Department of Internal Medicine, The Ohio State University and The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210 USA
| | - Ragavendra R. Baliga
- grid.412332.50000 0001 1545 0811Division of Cardiovascular Medicine, Department of Internal Medicine, Cardio-Oncology Center of Excellence, The Ohio State University Wexner Medical Center, OH, Columbus, OH 43210 USA
| | - Kristin L. Koenig
- grid.413944.f0000 0001 0447 4797Division of Hematology, Department of Medicine, The Ohio State University and The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210 USA
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Itzykson R, Santini V, Thepot S, Ades L, Chaffaut C, Giagounidis A, Morabito M, Droin N, Lübbert M, Sapena R, Nimubona S, Goasguen J, Wattel E, Zini G, Torregrosa Diaz JM, Germing U, Pelizzari AM, Park S, Jaekel N, Metzgeroth G, Onida F, Navarro R, Patriarca A, Stamatoullas A, Götze K, Puttrich M, Mossuto S, Solary E, Gloaguen S, Chevret S, Chermat F, Platzbecker U, Fenaux P. Decitabine Versus Hydroxyurea for Advanced Proliferative Chronic Myelomonocytic Leukemia: Results of a Randomized Phase III Trial Within the EMSCO Network. J Clin Oncol 2022; 41:1888-1897. [PMID: 36455187 DOI: 10.1200/jco.22.00437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Hydroxyurea (HY) is a reference treatment of advanced myeloproliferative neoplasms. We conducted a randomized phase III trial comparing decitabine (DAC) and HY in advanced myeloproliferative chronic myelomonocytic leukemias (CMML). PATIENTS AND METHODS Newly diagnosed myeloproliferative CMML patients with advanced disease were randomly assigned 1:1 to intravenous DAC (20 mg/m2/d days 1-5) or HY (1-4 g/d) in 28-day cycles. The primary end point was event-free survival (EFS), events being death and acute myelomonocytic leukemia (AML) transformation or progression. RESULTS One-hundred seventy patients received DAC (n = 84) or HY (n = 86). Median age was 72 and 74 years, and median WBC count 32.5 × 109/L and 31.2 × 109/L in the DAC and HY arms, respectively. Thirty-three percent of DAC and 31% of HY patients had CMML-2. Patients received a median of five DAC and six HY cycles. With a median follow-up of 17.5 months, median EFS was 12.1 months in the DAC arm and 10.3 months in the HY arm (hazard ratio [HR], 0.83; 95% CI, 0.59 to 1.16; P = .27). There was no significant interaction between treatment effect and blast or platelet count, anemia, CMML Prognostic Scoring System, Groupe Francophone des Myelodysplasies, or CMML Prognostic Scoring System–mol risk. Fifty-three (63%) DAC patients achieved a response compared with 30 (35%) HY patients ( P = .0004). Median duration of response was similar in both arms (DAC, 16.3 months; HY, 17.4 months; P = .90). Median overall survival was 18.4 months in the DAC arm and 21.9 months in the HY arm ( P = .67). Compared with HY, DAC significantly reduced the risk of CMML progression or transformation to acute myelomonocytic leukemia (cause-specific HR, 0.62; 95% CI, 0.41 to 0.94; P = .005) at the expense of death without progression or transformation (cause-specific HR, 1.55; 95% CI, 0.82 to 2.9; P = .04). CONCLUSION Compared with HY, frontline treatment with DAC did not improve EFS in patients with advanced myeloproliferative CMML (ClinicalTrials.gov identifier: NCT02214407 ).
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Affiliation(s)
- Raphael Itzykson
- Service Hématologie Adultes, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Génomes, biologie cellulaire et thérapeutique U944, INSERM, CNRS, Paris, France
- Groupe Francophone des Myélodysplasies, Paris, France
| | - Valeria Santini
- MDS Unit, DMSC; AOU Careggi, University of Florence, Florence, Italy
- Fondazione Italiana Sindromi Mielodisplastiche (FISiM-ets), Bologna, Italy
| | - Sylvain Thepot
- Groupe Francophone des Myélodysplasies, Paris, France
- Hematology Department CHU Angers, Université Angers, Angers, France
| | - Lionel Ades
- Service Hématologie Adultes, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
- Groupe Francophone des Myélodysplasies, Paris, France
- Service Hématologie Seniors, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Cendrine Chaffaut
- SBIM, APHP, Hôpital Saint-Louis, INSERM, UMR-1153, ECSTRA Team, Paris, France
| | - Aristoteles Giagounidis
- Marien Hospital, Klinik für Hämatologie, Onkologie und klinische Immunologie, D-Düsseldorf, Germany
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
| | - Margot Morabito
- Université Paris Saclay, INSERM U1287, Gustave Roussy Cancer Center, Villejuif, France
| | - Nathalie Droin
- Université Paris Saclay, INSERM U1287, Gustave Roussy Cancer Center, Villejuif, France
| | - Michael Lübbert
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine—University Medical Center Freiburg, Freiburg, Germany
| | - Rosa Sapena
- Groupe Francophone des Myélodysplasies, Paris, France
| | - Stanislas Nimubona
- Groupe Francophone des Myélodysplasies, Paris, France
- Service Hématologie Clinique adulte, CHU de Rennes, Rennes, France
| | | | - Eric Wattel
- Groupe Francophone des Myélodysplasies, Paris, France
- Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Gina Zini
- Hematology, Università Cattolica del S. Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jose Miguel Torregrosa Diaz
- Groupe Francophone des Myélodysplasies, Paris, France
- Service d’Hématologie Oncologique et Thérapie Cellulaire, CIC INSERM 1402, University Hospital of Poitiers, Poitiers, France
| | - Ulrich Germing
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
- Heinrich-Heine University Düsseldorf, Universitätsklinik Düsseldorf, Klinik für Hämatologie, Onkologie und Klinische Immunologie, Düsseldorf, Germany
| | - Anna Maria Pelizzari
- Fondazione Italiana Sindromi Mielodisplastiche (FISiM-ets), Bologna, Italy
- Hematology Unit, ASST Spedali Civili, Brescia, Italy
| | - Sophie Park
- Groupe Francophone des Myélodysplasies, Paris, France
- Université Grenoble Alpes, Hematology Department, CHU Grenoble Alpes, Grenoble, France
| | - Nadja Jaekel
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
- University Hospital Halle, Halle, Germany
| | - Georgia Metzgeroth
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Francesco Onida
- Fondazione Italiana Sindromi Mielodisplastiche (FISiM-ets), Bologna, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico - University of Milan, Hematology-BMT Unit, Milan, Italy
| | - Robert Navarro
- Groupe Francophone des Myélodysplasies, Paris, France
- Service d’Hématologie, CHU Montpellier, Montpellier, France
| | - Andrea Patriarca
- Fondazione Italiana Sindromi Mielodisplastiche (FISiM-ets), Bologna, Italy
- Hematology Unit, AOU «Maggiore della Carità» and University of Eastern Piedmont, I-28100, Novara, Italy
| | - Aspasia Stamatoullas
- Groupe Francophone des Myélodysplasies, Paris, France
- Centre Henri Becquerel, Rouen, France
| | - Katharina Götze
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
- Technical University of Munich, Department of Medicine III, Munich, Germany
| | - Martin Puttrich
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
- GWT-TUD GmbH, Dresden, Germany
| | - Sandra Mossuto
- Fondazione Italiana Sindromi Mielodisplastiche (FISiM-ets), Bologna, Italy
| | - Eric Solary
- Groupe Francophone des Myélodysplasies, Paris, France
- Université Paris Saclay, INSERM U1287, Gustave Roussy Cancer Center, Villejuif, France
- Department of Hematology, Gustave Roussy Cancer Center, Villejuif, France
| | - Silke Gloaguen
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
- Clinic and Polyclinic for Hematology, Cellular Therapy and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Sylvie Chevret
- SBIM, APHP, Hôpital Saint-Louis, INSERM, UMR-1153, ECSTRA Team, Paris, France
| | | | - Uwe Platzbecker
- Deutsche MDS-Studiengruppe, D-04103 Leipzig, Germany
- Clinic and Polyclinic for Hematology, Cellular Therapy and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Pierre Fenaux
- Service Hématologie Adultes, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
- Groupe Francophone des Myélodysplasies, Paris, France
- Service Hématologie Seniors, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
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