Here’s how readers responded to a You Make the Call question about the management of severe macrocytic anemia in a 73-year-old male patient with chronic myelomonocytic leukemia-1.
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I have used decitabine to cytoreduce the marrow and allow more effective erythropoiesis and have seen good palliation. I would also try epoetin alfa up to 100,000 U weekly.
Stephen Mayer, MD, PhD
Colorado Permanente Medical Group
Lone Tree, CO
Joseph Lebowicz, MD
Hematology Oncology Associates of Brooklyn
If the patient is otherwise in good health with good organ function, a trial of decitabine or azacitidine is reasonable.
Juan M. Alcantar, MD
Los Angeles, CA
I would treat with the goal to make him transfusion independent. With an erythropoietin level >500 mIU/mL, EPO supplements may not add much benefit. My choice would be a hypomethylating agent such as azacitidine SQ. This drug could make him transfusion independent and possibly prevent or delay potential transformation to AML.
Alejandro Calvo, MD
Kettering Cancer and Blood Specialists
I would prescribe 5-azacitidine. No erythropoietin. Age more or less precludes transplantation.
Henrik Hjorth-Hansen, MD, PhD
St. Olavs Hospital and Institute of Cancer Research and Molecular Medicine Norwegian University of Science and Technology
I would treat the patient with decitabine or 5-azacitidine.
Phnom Penh, Cambodia
A clinical trial is the first preference. I also suggest azacitidine or low-dose decitabine with close monitoring of his counts.
Usha Venkatraj, MD
Hope Cancer Center
College Station, TX
I would give azacitadine/decitabine to this patient.
Satvir Singh, MD
5-azacitidine; red blood cell transfusions prn.
If the patient meets criteria for intermediate or high risk, I would consider azacitidine. If not, then supportive care (transfusions) with iron management as needed.
Blair Ernst, MSc
Trillium Health Partners
This is probably erythroid aplasia, parvo-induced. I suggest treatment with gammaglobulins.
Víctor Salinas Rojas, MD
Mexico City, Mexico
Consider investigational therapy such as luspatercept and sotatercept against transforming growth factor beta superfamily.
- Almeida A, Fenaux P, List AF, et al. Recent advances in the treatment of lower-risk non-del(5q) myelodysplastic syndromes (MDS). Leuk Res. 2017 Jan;52:50-57.
- Acceleron Pharma, Inc. A Phase 2, Open Label, Ascending Dose Study of ACE-536for the Treatment of Anemia in Patients With Low or Intermediate-1 Risk Myelodysplastic Syndromes (MDS). In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2017 February 13]. Available from: https://www.clinicaltrials.gov/ct2/show/NCT01749514?term=ace-536&rank=3 NLM Identifier: NCT01749514
- An Open-label, Randomized, Phase 2, Parallel, Dose-Ranging, Multicenter Study of Sotaterceptfor the Treatment of Patients With Anemia and Low or Intermediate-1 Risk Myelodysplastic Syndromes or Non-proliferative Chronic Myelomonocytic Leukemia (CMML). In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2017 February 13]. Available from: https://www.clinicaltrials.gov/ct2/show/NCT01736683?term=sotatercept&rank=7 NLM Identifier: NCT01736683
Kailash Mosalpuria, MD, MPH
Nebraska Hematology Oncology
Azacitidine or decitabine. Next-generation sequencing may be helpful.
Elliot Dickman, MD, PhD
UH Seidman Cancer Center at Southwest General
Start hypomethylating agents such as azacitidine or decitabine along with PRBC support as erythropoietin level is >500 mIU/L.
Priyanka Samal, MD, DM, MBBS
I would treat him with a course of injected azacitidine.
Kannan Subramanian, MD, DM, MBBS
Azacitidine (4 cycles) plus blood transfusions, followed by reevaluation.
Radu Gologan, MD, PhD
I suggest supportive care (transfusion a/o chelation). There will probably be no erythropoietin response. What was the white blood cell count? And platelets? Performance status? Demethylating agents?
Donatella Baronciani, MD