What to prescribe for a patient with newly diagnosed CML who lives outside of the United States?

Associate Professor of Medicine (Hematology) at the Stanford Cancer Institute

This month, Jason Gotlib, MD, MS, answers a question about what to prescribe for a patient with newly diagnosed chronic myeloid leukemia who lives outside of the United States.

CLINICAL DILEMMA

I have a 66-year-old female patient with no medical problems, but with an elevated white blood cell count (23,000) and a left shift. Peripheral blood FISH showed atypical BCR/ABL1 rearrangement in 92 percent of cells, with deletion of the ASS1 gene adjacent to the ABL1 gene. A bone marrow biopsy had 2 percent blasts and was consistent with chronic-phase chronic myeloid leukemia (CML).

I was going to start nilotinib at a dose of 300 mg twice daily, because the patient has no comorbidities, but is there any other TKI that is better?

The patient lives in another country, and I was going to prescribe imatinib because it would be easier to obtain. But the patient’s daughter wanted what would be prescribed in the United States.

EXPERTS MAKE THE CALL

For chronic-phase CML, imatinib, dasatinib, or nilotinib are appropriate front-line therapy options for this indication per National Comprehensive Cancer Network guidelines.1 However, my preference is nilotinib or dasatinib based on a higher proportion of patients who achieve deeper molecular responses. Then it comes down to patient preference regarding daily dosing (dasatinib) 100 mg daily versus twice daily dosing scheduled around food intake (nilotinib) 300 mg bid. Further, are there any comorbidities in the patient’s history that would influence selection of one of the three drugs, based on the side effect profiles of each drug? And lastly, for cost reasons and availability, if imatinib is easier to obtain, or the only drug available, this may make it preferable, and certainly needs to be weighed into the decision making.

Reference

  1. NCCN Clinical Practice Guidelines in Oncology, Chronic Myelogenous Leukemia, Version 1.2015.

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