Tim may very well be right. Although the PAP appears normal on echo, the only real way to diagnose PAH properly is with a right heart catheterization. Given this individual's symptoms, this should definitely be done if there are any thoughts of continuing current therapy. If there is no desire to take the aggressive route, then I would agree completely that a switch to imatinib on the presumption that this is early PH/PAH should be done.

She has achieved an optimal result on dasatinib at this stage and I would be quite worried about her symptoms and elevated PAP. My concern is that a patient with early features of pulmonary arterial hypertension (PAH) might develop rapidly progressive PAH if they continue dasatinib therapy. Even though the PAP is only mildly elevated at this stage she is symptomatic. My preference would be to switch to imatinib now. You always have nilotinib if she loses her excellent response. I agree that lower dose dasatinib would not necessarily be safer from the pulmonary perspective.

I have a 75 year old female patient who complained of a persistent dry cough and exertional dyspnea (Nov 2016). She also has intermittent nausea, which is not clearly related to food. She attributes these problems to dasatinib (currently 100mg/day).

Further tests revealed no pleural effusion clinically. PFTs showed normal spirometry, pO2, and lung volumes, but a DLCO only 50% of predicted (non-smoker). EchoCG showed mild pulmonary hypertension, PAP about 30 mmHg.

She has been on treatment for only about 9 months and achieved MMR already by 6 months. Her risk score wasn’t especially high, so she could switch to imatinib. I would do a dasatinib level if I could, with a view to decreasing the dose, but I don’t know whether there is evidence that pulm HT (like pl eff) is related to trough levels. The PAP is not very high, so I could also wait and repeat it in 3 months.

I would appreciate some further opinions on whether to switch to imatinib or lower her dasatanib dosage.