I am a bit worried about the ongoing risk of major cardiac events if you continue nilotinib. We have seen some recurrent cases. I would probably prefer to switch her to dasatinib even though she already has pleural effusions bilaterally. This is more manageable and less life threatening than another cardiac event.

Regards
Tim

I am a haematology consultant and wish to seek your opinion on a female patient in her early 60s who has had CML for 10 yrs. She was on imatinib until a year ago and was then changed to nilotinib 400mg BID due to a rise in BCR-ABL transcript levels.

In the last 4 weeks she has presented with triple vessel coronary heart disease not amenable to stenting or bypass. Her echocardiogram is normal but she does have clinical feature of cardiac impairment with small bilateral pleural effusions and her proBNP is elevated. Her only prior cardiac risk factor was elevated cholesterol for which she has been on a statin.

According to Kim et al, Haematologica 2012, they had seven patients (out of 81) with coronary heart disease and in the majority of these the nilotinib was continued without any adverse long term outcomes and they could not conclude on the causality of nilotinib. My inclination is to continue the nilotinib at current dose and monitor closely and I wondered what your advice and experience with such settings is, as we have few patients on nilotinib as it is not yet funded in New Zealand.

I would be very interested in everyone's thoughts and would hence like to submit this case to the iCMLf forum.

Sincerely,
Shingi Chiruka