You Made the Call
We asked, and you answered! Here are
a few responses from this month’s “You
Make the Call.”
For the full description of the clinical
dilemma, and to see how the expert
responded, turn to page 48.
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. 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.
1) If the patient has a low-risk disease,
I would prefer imatinib 400 mg/day
and monitor molecular and cytogenetic
responses. If she fails to achieve optimal
response at any given time point, I would
then consider switching to second-generation TKIs if there is no non-adherence to
imatinib. Because although the lady does
not have any comorbidities, second-generation TKIs have many side effects that
can be observed with relatively higher
rates in elderly cases than young patients.
I would go with imatinib, especially if she
has a low (not high risk) Sokal score.
2) If the patient has a high-risk CML,
maybe I would go for second-generation
TKIs, since in these patients choosing a
second-generation TKI can be beneficial
in inducing deeper and faster molecular
responses.
A. Emre Eşkazan, MD
Istanbul University
Istanbul, Turkey
I would prescribe imatinib as first-line treatment, if I were in the United States, too.
Juan M. Alcantar, MD
UCLA Health
Eran Zimran, MD
Jerusalem, Israel
I agree with starting nilotinib.
Adel Z. Makary, MD
Danville, PA
Imatinib.
Phillip O. Periman, MD
Texas Oncology, P.A.
Amarillo, TX
Imatinib is a perfectly good choice if the
patient has a low Sokal risk score.
Sarit Assouline, MDCM, MSc
McGill University
Jewish General Hospital
Montreal, Quebec
I would discuss with my patient her options noting two issues:
1) The chronicity of the disease and
treatment is likely life-long.
2) The pros and cons of imatinib versus
nilotinib … I would emphasize the small
difference in the likelihood of obtaining
complete response (CR); still a valid option if imatinib does not induce CR.
I would prescribe what my patient is
more likely to be compliant with, as she
can be enthusiastic early on at time of
diagnosis, but can’t maintain the treatment recommended afterward. In this
case, imatinib is more likely to be the
choice, as more affordable with many
generics available in different countries.
Sana Al Sukhun, MD, MSc
President of Jordan Oncology Society.
Diplomat, American Board of Medical
Oncology/ Hematology
Amman, Jordan
Imatinib is a good choice as well. If suboptimal or even poor response in terms
of molecular remission is seen, reconsideration of treatment strategy is needed.
Bernhard Lammle, MD
Mainz, Germany
See more reader responses at ashclinicalnews.org/
category/training-education/you-make-the-call.