Clinical Case Discussion Forum
To share and enhance best practice management of CML, experts and interested clinicians can discuss difficult or interesting CML cases here. Physicians submit a brief history of the patient and the case for discussion using this forum.
Frontline investigations and choice of TKI
Topic
Frontline investigations and choice of TKI
was created by
Dr Saurabh Bhave
Dr Saurabh Bhave
India
05:12 05 December 2017
We have a 74 year diabetic lady
Newly diagnosed CML
Sokal score high
Questions
1. Are you doing Bone marrow at diagnosis in 74 year old lady ?
2. Your choice of TKI in this patient will be imatinib or dasatinib ?
We still do a bone marrow at diagnosis to exclude advanced phase disease and to look at cytogenetics. I agree the value is limited in patients where an allograft would never be a consideration and I wouldn’t push too hard in these patients if they were not keen to have it done.
I would generally prefer a second gen TKI in patients with high Sokal score and dasatinib would be a good choice in this lady. I might not use 100 mg/day though – given her age-related high risk of pleural effusion. I would use 70 mg/day and only increase if her molecular response was not optimal.
Definitely agree with Tim with one minor exception. Given her age and co-morbidities, I would go with 50mg DAS. There are data from the OPTIM study, presented and soon to be published I hope, that suggests that 50mg is all that is needed. Increase dose if response is poor. Would not chase MR4.5 as an endpoint, but at least a stable CCyR or MMR. TFR should not be a major target on your radar. If she responds well and runs into toxicities, consider a switch to imatinib. Unless resistance and the appropriate mutation dictates, would avoid nilotinib because of the diabetes.