Agree with Prof Saglio. So long as she has sustained CCyR, would not change. It should be noted as well, that on occasion, some patients exhibit a two phase response and after a plateau in response such as this, a subsequent response improvement after a period of time, even years, can sometimes be observed.

The patient showed a slow response to nilotinib therapy, in part due to the onset of toxicity that hampered a correct assumption and finally lead to discontinuation of the initially chosen drug. At the moment, even after switching to Dasatinib, the patient shows a persistent suboptimal response, lacking the achievement of MMR. However for the moment I would not change the therapy as there is no loss of CCyR and therefore no overt failure. For the same reason and due to the age of the patient, I would not consider the option of an alloSCT. I would follow this patient carefully and would check about her compliance to therapy, maybe related to fears related to the previous toxicity .

I have a 60 year old woman diagnosed chronic phase CML March 2012. She has a history of hypertension only. She started nilotinib April 2012. Within one month she had achieved a CHR but also developed a Grade III transaminitis requiring hold of the drug. This resolved within few weeks and I restarted at reduced dose as per the monograph. She developed recurrent significant transaminitis. I changed to Dasatinib in September 2012. She achieved a complete cytogenetic response by September 2013, however at 18 months (March 2014) she still had not achieved an MMR – BCR-ABL IS of 0.139. Serial measurement shows persistent CCR with most recent BCR-ABL IS of 0.239 (June 2014). Mutational analysis of BCR-ABL is negative. Bone marrow confirms CCR and does not demonstrate any new cytogenetic abnormalities. Her sibs are being typed. She is a very risk averse individual when it comes to therapy and wishes to simply continue to follow along. I had considered increasing the dose of Dasatinib. I am unsure of the role of the newer TKI’s here. I wonder what other’s approach to this situation would be.