Chronic%20myeloid%20leukemia Treatment

• In general, the choice of 1st-line therapy may depend on risk score, physician's experience, age, ability to tolerate therapy and comorbid conditions
• TKIs are recommended 1st-line therapy for patients with CP-CML and AP-CML
  • Both 1st- and 2nd-generation TKIs are recommended as primary treatment for newly diagnosed low-risk CP-CML patients
  • Second-generation TKIs Dasatinib, Nilotinib and Bosutinib are recommended for newly diagnosed CP-CML patients with intermediate- to high-risk
    • Second-generation TKIs are preferred over Imatinib therapy for younger patients particularly females desiring fertility
    • First-generation TKI Imatinib may be preferred for older patients with comorbidities, especially cardiovascular comorbidities
    • Studies showed that Bosutinib, Dasatinib and Nilotinib possess higher major molecular response (MMR) rate and deeper molecular responses compared to Imatinib
  • Dasatinib or Bosutinib are preferred TKIs for CP-CML patients with history of arrhythmia, cardiac disorders, pancreatitis, or increased blood glucose
  • For CP-CML patients with pulmonary disorders and those at increased risk for pleural effusion, Nilotinib or Bosutinib are preferred
  • For patients with AP-CML, 2nd- and 3rd-generation TKIs are recommended as primary treatment for accelerated phase disease, ALL-type induction chemotherapy with TKI or TKI with steroids for lymphoid BP-CML, and AML-type induction chemotherapy with TKI or TKI monotherapy for myeloid BP-CML
• For patients with disease progression despite previous monotherapy with TKI, an alternate TKI not previously given may be considered
• Omacetaxine therapy or Allo-HCT may be considered for AP-CML patients unresponsive to multi-TKI therapy

Adherence to Tyrosine Kinase Inhibitor (TKI) Therapy

• Predicts the achievement of deep molecular response (DMR) on standard-dose Imatinib
• The marker that identifies a non-adherent CP-CML patient is the BCR::ABL1 doubling time
• Educate the patient on their adherence to tyrosine kinase inhibitor therapy and monitor them closely
• Non-adherence may result to poorer treatment response that can result to loss of MMR, hematologic failure, cytogenic relapse and treatment failure
• Appropriate management of the side effects will improve patient adherence

Discontinuation of TKI Therapy

• May be considered if all of the following criteria are present:
  • Patient aged ≥18 years old
  • Disease in CP without any history of AP or BP
  • At least 3 years of TKI therapy
  • Presence of BCR::ABL1 transcripts at time of diagnosis
  • ≥2 years of stable molecular response (molecular response 4 [MR4]; BCR::ABL1 ≤0.01% IS) for ≥2 years in at least 4 tests obtained ≥3 months apart
  • Reliable qPCR test (MR4.5 and BCR::ABL1 ≤0.0032% IS) easily accessible with results processed within 2 weeks
  • Able to comply with strict follow-up in patients with MMR (MR3; BCR::ABL1≤0.1% IS) after TKI discontinuation: Molecular monitoring conducted monthly for the 1st 6 months, every 2 months for the next 6 months, then quarterly thereafter
  • Can promptly resume TKI therapy (within 4 weeks) after loss of MMR with molecular monitoring every 4 weeks until MMR is achieved, then every 12 weeks monitoring thereafter
    • Perform BCR::ABL1 testing for patients who do not achieve MMR 3 months after resuming TKI therapy, and molecular monitoring should be conducted monthly for 6 months
  • Patient agrees to report any of the following:
    • Significant adverse events related to TKI therapy discontinuation
    • Disease phase progresses to AP or BP
    • MMR has not been achieved 3 months after resumption of treatment
• Should only be considered in patients who are eligible for clinical trial
• May consider temporarily stopping TKI treatment in patients with history of treatment change only due to intolerance, typical e13a2 or e14a2 BCR::ABL1 transcripts, >5 years on TKI therapy (>4 years if 2nd-generation TKI used), DMR of >2 years, and history of treatment failure
• In patients with responsive disease, continuation of TKI therapy is recommended

Clinical Trials

• Considerations for enrollment in clinical trials:
  • In patients with AP-CML or BP-CML
  • In patients with treatment failure after Imatinib therapy
  • For patients with BCR::ABL1 transcripts >10% (IS) after initial treatment with 2nd-line TKIs at 3-month evaluation
  • For patients with BCR::ABL1 transcripts >10% (IS) or lack of partial cytogenetic response (PCyR) on bone marrow cytogenetics after initial treatment with 2nd-line TKIs at 6-month evaluation
  • For patients with cytogenic relapse, or less than PCyR or BCR::ABL1 transcripts >10% (IS) at 12-month evaluation

Targeted Cancer Therapy
First Generation Tyrosine Kinase Inhibitors (TKI)

Imatinib

• Belongs to a class of signal transduction inhibitors (STIs) that interferes with the intracellular signaling pathways associated with malignancies
• Inhibits the BCR::ABL1 tyrosine protein kinase in all phases of chronic myeloid leukemia
• Recommended as 1st-line treatment for low-risk patients with chronic phase chronic myeloid leukemia (CP-CML) and advanced phase chronic myeloid leukemia (AP-CML) and 2nd-line treatment for patients at intermediate- to high-risk with CP-CML and advanced phase CML
  • Several studies showed cytogenic response, hematologic response, decreased relapse and disease progression, and high overall survival (OS) in patients given Imatinib therapy

Second Generation TKI

Bosutinib

• An oral multi-TKI that is used to treat adult patients with chronic phase, accelerated phase or blast phase Ph-positive (Ph+) chronic myeloid leukemia (CML) with resistance or intolerance to previous therapy (eg Imatinib, Dasatinib and Nilotinib)
• Inhibits BCR::ABL1 kinase that promotes CMLand Src-family of kinases (eg Src, Lyn and Hck)
• More potent for the BCR::ABL1 kinase than Imatinib
• Not an efficient substrate for multidrug resistant transporters
• Used for the management of cytogenetic or hematologic resistance to TKIs and in patients with E255K/V, F317L/V/I/C, F359V/C/I, T315A, or Y253H mutations
• Recommended 1st-line treatment for newly diagnosed patients with CP-CML with any risk score
• Treatment option for CP-CML patients previously treated with Dasatinib or Nilotinib
• Should not be given in patients with T315I, V299L, G250E, or F317L mutations

Dasatinib

• An oral multi-TKI and is more potent in the inhibition of ABL than Imatinib
• Inhibits Src tyrosine kinase, BCR::ABL and Imatinib-resistant mutations of BCR::ABL and binds to both active and inactive conformation of the ABL kinase domain
• Recommended for all phases of CML with resistance or intolerance to prior therapy of Imatinib, Ph+ ALL with resistance or intolerance to prior therapy and in newly diagnosed Ph+ CML in the chronic phase
• Preferred 1st-line treatment for patients with CP-CML with intermediate- to high-risk score
  
  • Also preferred in patients with history of arrhythmia, heart disease, pancreatitis and hyperglycemia
• Used for the management of cytogenetic or hematologic resistance to TKIs and in patients with Y253H, E255K/V or F359V/C/I mutations
• Should not be given in patients with T315I/A, F317L/V/I/C, or V299L mutations

Nilotinib

• Used for adult patients who are newly diagnosed with Ph+ CP-CML
• Also used to treat chronic and accelerated Ph+ CML patients who are intolerant or resistant to a prior therapy that includes Imatinib
• Preferred 1st-line treatment for patients with CP-CML with intermediate- to high-risk score
• Selectively inhibits the BCR::ABL1 tyrosine kinase and enhances the binding site affinity which makes Nilotinib 30 times more potent than Imatinib in Imatinib-sensitive CML cell lines and 3-7 times more potent in Imatinib-resistant CML cell lines
• Used for the management of cytogenetic or hematologic resistance to TKIs and in patients with F317L/V/I/C, T315A or V299L mutations
• Should not be given in patients with T315I, Y253H, E255K/V, or F359V/C/I mutations

Radotinib

• An oral TKI that inhibits the BCR-ABL1 fusion protein, approved only in South Korea, is currently being studied in other countries for its potential for antineoplastic activity in CML

Third Generation TKI

Asciminib

• An ABL/BCR::ABL1 TKI that inhibits ABL1 kinase activity by binding to the myristoyl pocket of the protein which results in the formation of an inactive kinase configuration
• Treatment option for CP-CML T315I mutation-positive patients and/or CP-CML patients with resistance or intolerance to at least 2 prior TKIs
• Should not be given in patients with A337T or P465S mutations

Ponatinib

• An oral multi-kinase inhibitor that inhibits the ABL and T315l mutant ABL genes
• Used for the treatment of T3151-positive CP-, AP-, or BP-CML or T315l-positive Ph+ALL and in patients with CP-, AP-, or BP-CML or Ph+ALL for patients when no other TKI is indicated
• Treatment option for CP-CML patients unresponsive to multiple TKI therapy

Management of TKI Therapy Toxicities

Asciminib

• ANC <1.0 x 10⁹/L, and/or platelets <50 x 10⁹/L
  • Withhold treatment until ANC reaches ≥1.0 x 10⁹/L and platelet count ≥50 x 10⁹/L
    • Resume Asciminib at reduced dose for presence of recurrent severe thrombocytopenia and/or neutropenia
  • May resume Asciminib treatment or may reduce dose when blood count returns to normal within 2 weeks
• Withhold therapy for any of the following:
  • Elevated serum amylase and/or lipase (>2.0 x ULN)
    • May resume treatment at reduced dose once serum levels return to <1.5 x ULN
    • Permanently discontinue if recurrence occurs even at reduced dose or if serum levels remain at <1.5 x ULN
  • Grade ≥3 hypersensitivity or cardiovascular toxicity
    • May resume treatment at reduced dose when symptoms resolve to grade ≤1
    • Permanently discontinue if signs/symptoms persist
• Withhold treatment, reduce dose, or permanently discontinue therapy if hypertension is not medically controlled
• Patients currently undergoing treatment with a strong CYP3A4 inhibitor/substrate or P‑glycoprotein substrate should be closely monitored for any adverse effects; concomitant use of Asciminib with CYP2C9 substrates should be avoided

Bosutinib

• ANC <1.0 x 10⁹/L or platelet count <50 x 10⁹/L
• Withhold treatment until ANC reaches ≥1.0 x 10⁹/L and platelet count ≥50 x 10⁹/L
• May resume Bosutinib treatment when blood count returns to normal within 2 weeks
• Reduce dose to 100 mg if blood counts remain low after 2 weeks; further dose reduction to 100 mg more may be considered for recurrence of cytopenia
• Combination with growth factors may be considered for resistant neutropenia and thrombocytopenia
• Transfusion support may be considered in patients with symptomatic grade 3-4 anemia
• Withhold therapy if patient's liver transaminases >5 x IULN
• Resume therapy at 400 mg daily when liver transaminases are reduced to ≤2.5 x IULN
• Discontinue Bosutinib if recovery takes longer than 4 weeks, or if with transaminase elevations >3 x IULN, bilirubin >2 x IULN, and alkaline phosphatase <2 x ULN
• Withhold therapy if with grade 3-4 diarrhea, rashes, and other clinically significant, moderate, or severe non-hematologic toxicities until symptoms resolve
• May resume treatment at 400 mg once daily when toxicity has resolved (ie diarrhea resolves to grade ≤1)

Dasatinib

• CP-CML with ANC <0.5 x 10⁹/L or platelet count <50 x 10⁹/L
  
  • Withhold therapy until ANC ≥1.0 x 10⁹/L and platelet count ≥50 x 10⁹/L, if platelet count is <25 x 10⁹/L, or for recurrence of ANC <0.5 x 10⁹/L for >7 days
  • May resume treatment if blood count returns to normal after ≤7 days or at a reduced dose of 80 mg once daily for recurrence; reduce dose further to 50 mg once daily or discontinue treatment if at 3rd recurrence
• AP-CML and BP-CML with ANC <0.5 x 10⁹/L and/or platelet count <10 x 10⁹/L
  
  • Withhold treatment if patient develops cytopenia unrelated to CML, then resume at initial dose if with ANC ≥1.0 x 10⁹/L and platelet count ≥20 x 10⁹/L, or at a reduced dose of 100 mg/day if for recurrence, or at 80 mg once daily for 3rd recurrence 
• Combination with growth factors may be considered for resistant neutropenia and thrombocytopenia
• Transfusion support may be considered in patients with symptomatic grade 3-4 anemia
• Dasatinib should be discontinued permanently for confirmed presence of pulmonary arterial hypertension
• Withhold therapy if with rashes and severe non-hematologic toxicities until symptoms resolve
  
  • May resume treatment at reduced dose depending on severity of adverse effect

Imatinib

• CP-CML with ANC <1.0 x 10⁹/L and/or platelet count <50 x 10⁹/L
  
  • Withhold therapy until ANC ≥1.5 x 10⁹/L and/or platelet count ≥75 x 10⁹/L, then resume at 400 mg initial dose, or 300 mg initial dose for recurrence
• AP-CML and blast phase chronic myeloid leukemia (BP-CML) with ANC <0.5 x 10⁹/L and/or platelet count <10 x 10⁹/L
  
  • Reduce dose to 400 mg if patient develops cytopenia unrelated to CML
  • Reduce dose further to 300 mg if with persistent neutropenia after 2 weeks
  • Withhold Imatinib if still with cytopenia after 4 weeks, then resume at 300 mg dose if ANC ≥1.0 x 10⁹/L and platelet count ≥20 x 10⁹/L
• Combination with growth factors may be considered for resistant neutropenia
• Transfusion support may be considered in patients with symptomatic grade 3-4 anemia
• Withhold therapy if patient has bilirubin >3 x institutional upper limit of normal (IULN) or liver transaminases >5 x IULN
  
  • Resume therapy when bilirubin level is reduced to <1.5 x ULN and liver transaminases to <2.5 x IULN
• Interrupt administration if any the following are present: Severe hepatotoxicity, severe fluid retention, rashes

Nilotinib

• Monitor serum potassium and magnesium levels, ECG, glucose levels
• Withhold treatment for any of the following:
  
  • ECG with QTc >480 msec
    
    • May resume treatment within 2 weeks at prior dose if with QTcF <450 msec and within 20 msec of baseline
    • May resume at reduced dose if QTcF between 450-480 msec after 2 weeks
    • Discontinue Nilotinib if QTcF returns to >480 msec after dose reduction
  • CP or AP, ANC <1.0 x 10⁹/L and/or platelet count <50 x 10⁹/L
    • May resume treatment within 2 weeks at prior dose if ANC >1.0 x 10⁹/L and/or platelet count >50 x 10⁹/L
    • May reduce dose to 400 mg if blood counts remain low for >2 weeks
  • Elevated serum lipase, amylase, bilirubin, or hepatic transaminases grade ≥3
    • May resume at reduced dose of 400 mg if serum levels return to grade ≤1
• Discontinue Nilotinib if with confirmed peripheral arterial occlusive disease
• Combination with growth factors may be considered for resistant neutropenia and thrombocytopenia
• Transfusion support may be considered in patients with symptomatic grade 3-4 anemia

Ponatinib

• Withhold treatment for any of the following:
  
  • ANC <1.0 x 10⁹/L and/or platelet count <50 x 10⁹/L
    
    • May resume therapy at initial dose (45 mg), at 30 mg if at 2nd occurrence, and at 15 mg if at 3rd occurrence when results are ANC ≥1.5 x 10⁹/L and platelet count ≥75 x 10⁹/L
  • Elevated serum lipase (symptomatic grade 1/2), amylase, bilirubin, or hepatic transaminases grade >3 x IULN (grade ≥2)
    
    • May resume treatment at reduced dose in patients with liver transaminase <3 x IULN, serum lipase <1.5 x ULN or ≤grade 1
  • Symptomatic grade 3 pancreatitis
    
    • Consider treatment resumption when serum lipase levels return to ≤grade 1 at a lower dose
  • Cerebral or GI hemorrhage, rashes, or fluid retention
• Discontinue Ponatinib if patients receiving 15 mg doses present with liver transaminase of >3 x IULN, grade 4 symptomatic pancreatitis, and in patients with AST/ALT ≥3 x ULN plus bilirubin >2 x ULN and alkaline phosphatase <2 x ULN
• Monitor for thromboembolism, cardiac function, and hepatic function
• Combination with growth factors may be considered for resistant neutropenia and thrombocytopenia
• Transfusion support may be considered in patients with symptomatic grade 3-4 anemia

Cytotoxic Chemotherapy

Hydroxyurea

• An antimetabolite that rapidly reduces high white blood cell counts
• Inhibits the ribonucleotide reductase and DNA synthesis and does not interfere with protein or RNA synthesis
• Treatment option for symptomatic leukocytosis or thrombocytosis awaiting confirmation of BCR::ABL1

Omacetaxine mepesuccinate

• A cephalotaxine ester that inhibits protein synthesis by binding to the A-site located at the peptidyl-transferase center of the large ribosomal subunit and reduces the protein levels of BCR::ABL and myeloid leukemia cell 1 (MCL-1) that is independent of the direct BCR::ABL binding
• Used to treat patients who have CP-CML or AP-CML with disease progression that is resistant or intolerant to 2 or more TKIs and for patients with T315I mutation
• Reported adverse effects with Omacetaxine therapy include grade 3 or 4 hyperglycemia and CBC abnormalities
  
  • Delay treatment if patient presents with ANC <0.5 x 10⁹/L or platelet count <50 x 10⁹/L
  • May resume at reduced dose every 2 days for the next cycle if with ANC ≥1.0 x 10⁹/L and platelet count ≥50 x 10⁹/L
  • Avoid in patients with poorly controlled diabetes until good glycemic control has been established

Cancer Immunotherapy

• Clinical trials on the therapeutic potential of Pegylated interferon α in combination with TKIs in CP-CML showed promising results