You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question
submitted through the Consult-a-Colleague program and post the expert’s
response. But, what would YOU do? We’ll also pose a submitted question
and ask you to send your responses. See how your answer matches up to the
experts in the next print issue.
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.
Consult a Colleague
Through ASH
Consult a Colleague is a service for ASH
members that helps facilitate the exchange of information between hematologists and their peers. ASH members
can seek consultation on clinical cases
from qualified experts in 11 categories:
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
Experts Make the Call
• Lymphomas
• Lymphoproliferative disorders
Jason Gotlib, MD, MS
Associate Professor of Medicine (Hematology)
Stanford Cancer Institute
For chronic-phase
CML, imatinib,
dasatinib, or nilotinib
are appropriate frontline 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.
• Leukemias
• Multiple myeloma & Waldenström
macroglobulinemia
• Myeloproliferative disorders
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
Have a puzzling clinical dilemma?
Submit a question, and read more
about Consult-a-Colleague volunteers at
hematology.org/Clinicians/Consult.aspx
or scan the QR code.
REFERENCE
1. NCCN Clinical Practice Guidelines in Oncology, Chronic Myelogenous Leukemia, Version 1.2015.
DISCLAIMER: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and
disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is
solely at your own risk.
Next Month’s Clinical Dilemma:
I have a patient with type 1 von Willebrand
disease who is about to undergo wisdom
48
ASH Clinical News
teeth extraction. Her activity level is undetectable, and her factor VIII is 21%. Is
40 µ/kg one hour prior to the procedure
and 20 µ/kg every eight hours for three
days after the procedure, with aminocaproic acid as needed, acceptable prophylaxis?
*If you have a request related to a
hematologic disorder not listed here, please
email your recommendation to ashconsult@
hematology.org so it can be considered for
addition in the future.
How would you respond? Email us at
[email protected].
July 2016