Navigating CML management in Saudi Arabia

Following the inaugural meeting on treatment-free remission (TFR), this second Saudi Arabian Regional Discussion Group focused on two important areas of everyday CML management: anticipating and managing acute TKI toxicity and adverse events, and CML in pregnancy.

The discussion brought together Dr Iman Alhazmi and Professor Binyam Usman from Saudi Arabia alongside international experts Professor Giuseppe Saglio (Italy) and Professor Michael Mauro (USA). As always with the iCMLf Regional Discussions, it was real clinical cases and open discussion that formed the basis of the learning. Across both topics, the cases reinforced a recurring theme: effective CML management requires more than selecting the right TKI. Treatment decisions must take account of comorbidities, toxicity, adherence, quality of life, reproductive goals and, most importantly, the individual priorities of each patient.

#1: Anticipating and managing acute TKI toxicity and adverse events

Led by Dr Usman, the first session explored how TKI-related toxicities can affect treatment selection, adherence and long-term CML management. Through two contrasting cases: 1) an older patient with cardiovascular comorbidities and persistent imatinib intolerance, and 2) a younger patient experiencing severe cytopenias and pulmonary complications after starting dasatinib, the discussion highlighted the importance of tailoring treatment to both the patient and the toxicity profile.

Key discussion points

•  TKI selection should consider comorbidities and the individual safety profile of each treatment. For patients with significant cardiovascular disease, imatinib may remain an appropriate option because of its established cardiovascular safety profile.
• Treatment goals should reflect the individual patient. Maintaining safe and effective disease control may be more important than achieving a deep molecular response or pursuing TFR in older patients with substantial comorbidities.
• Adverse events can have a major impact on adherence. Understanding the patient's experience, addressing concerns and agreeing on a treatment approach they are willing to follow are essential for maintaining CML control.
• Severe cytopenias can occur early during TKI therapy and require prompt assessment and management. Growth factors may be considered in selected patients with significant myelosuppression.
• Pleural effusion is a recognised complication of dasatinib, while other pulmonary toxicities are less common. Respiratory symtoms should continue to be assessed even after years of treatment, as complications can also occur later.
• Dose optimisation was discussed as an important strategy for balancing efficacy and tolerability. Different approaches to dasatinib dosing were highlighted, including starting at the standard dose followed by reduction, or using a lower starting dose in selected patients.

Take-home message: Effective management of TKI toxicity requires an individualised approach that balances disease control with comorbidities, tolerability and quality of life. Recognising and addressing adverse events early can support adherence and allow patients to remain successfully on long-term therapy.

#2: CML in pregnancy

The second session, led by Dr Alhazmi, explored CML management before and during pregnancy through several real-world cases, ranging from CML diagnosed during pregnancy to planned treatment interruption in women wishing to start, or expand their families. The discussion emphasised that pregnancy is increasingly a realistic option for women with CML, but requires careful planning, monitoring and shared decision-making.

Key discussion points

• Fertility and family planning should be discussed with younger patients early in their CML journey, ideally from diagnosis, so that reproductive goals can be incorporated into long-term treatment planning.
• TKIs should generally be avoided during the critical period of organogenesis. If treatment is required during pregnancy, the choice and timing of therapy need to balance maternal disease control with potential foetal risks.
• Interferon can be used during pregnancy to maintain haematological control, while leukapheresis may provide an option when rapid cytoreduction is required.
• Later in pregnancy, imatinib or nilotinib may be considered in selected patients if treatment is necessary. Dasatinib should be avoided because it crosses the placenta.
• For an unplanned pregnancy, the TKI should generally be stopped once pregnancy is confirmed and subsequent management determined according to disease status, gestational stage and individual risk.
• Planned pregnancy is ideally considered when CML is well controlled. TFR eligibility provides an optimal opportunity but waiting until formal TFR criteria are achieved may not be appropriate for every woman, particularly where age and fertility are important
  considerations.
• Open counselling and shared decision-making are essential. Setting realistic treatment milestones can support adherence while helping women work towards their family- planning goals.

Take-home message: Pregnancy and CML can be successfully managed in many patients. Early family-planning discussions, good disease control and close monitoring allow treatment decisions to be tailored to the individual woman while balancing maternal safety, foetal risk and reproductive goals.

In summary

The second Saudi Arabian Regional Discussion Group once again demonstrated the value of combining international expertise with regional experience and real-world case discussions. From managing challenging TKI toxicities to supporting women with CML through pregnancy and family planning, the meeting highlighted practical strategies for translating evolving evidence into patient-centred care.

The discussion also reinforced the importance of open communication and shared decision- making, helping patients remain engaged with treatment while ensuring that management decisions reflect their individual circumstances and priorities.

With thanks to Novartis for their support of this iCMLf Regional Discussion Group series.