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× To share and enhance best practice management of CML, experts and interested clinicians can discuss difficult or interesting CML patient cases here. Clinicians submit a brief history of the patient and the case for discussion (no more than 200 words) by posting it in this forum ("+ NEW TOPIC" button below).

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Frontline investigations and choice of TKI

  • Saurabh Bhave
  • Saurabh Bhave's Avatar Topic Author
1 year 3 months ago #1601 by Saurabh Bhave
Frontline investigations and choice of TKI was created by Saurabh Bhave
We have a 74 year diabetic lady
Newly diagnosed CML
Sokal score high

Questions

1. Are you doing Bone marrow at diagnosis in 74 year old lady ?
2. Your choice of TKI in this patient will be imatinib or dasatinib ?
  • Tim Hughes
  • Tim Hughes's Avatar Topic Author
1 year 3 months ago #1602 by Tim Hughes
Replied by Tim Hughes on topic Frontline investigations and choice of TKI
We still do a bone marrow at diagnosis to exclude advanced phase disease and to look at cytogenetics. I agree the value is limited in patients where an allograft would never be a consideration and I wouldn’t push too hard in these patients if they were not keen to have it done.

I would generally prefer a second gen TKI in patients with high Sokal score and dasatinib would be a good choice in this lady. I might not use 100 mg/day though – given her age-related high risk of pleural effusion. I would use 70 mg/day and only increase if her molecular response was not optimal.
  • JEFF LIPTON
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1 year 3 months ago #1603 by JEFF LIPTON
Replied by JEFF LIPTON on topic Frontline investigations and choice of TKI
Definitely agree with Tim with one minor exception. Given her age and co-morbidities, I would go with 50mg DAS. There are data from the OPTIM study, presented and soon to be published I hope, that suggests that 50mg is all that is needed. Increase dose if response is poor. Would not chase MR4.5 as an endpoint, but at least a stable CCyR or MMR. TFR should not be a major target on your radar. If she responds well and runs into toxicities, consider a switch to imatinib. Unless resistance and the appropriate mutation dictates, would avoid nilotinib because of the diabetes.
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