Hi Ruth,
His response to nilotinib 400 mg bd has been slow but steady – he has fallen from 2% in Aug 2017 to 0.3% May 2018. It is now over 2 years since he started TKI therapy so his risk of transforming to BC is quite small. The outcome for patients who are in CCyR at 2 years compared to the subset who are in MMR is fairly similar. So I would be reluctant to switch or dose increase at the moment. We know the 400 mg bd dose of nilotinib doubles the risk of vascular events compared to 300 mg bd so I would be worried about the vascular risk of 600 mg bd, plus there is limited data on improving efficacy with this dose. Ponatinib is worth considering, but given the vascular risk profile, probably only if his BCR-ABL increases to over 1%. I agree a marrow study would be reasonable to reassure you that he remains in CCyR. I wouldn’t consider an allograft unless he transforms or subsequently fails ponatinib therapy.
Tim