Highlights

In my own practice my preference is to start [chronic-phase] patients on a second-generation TKI irrespective of risk profile. Some insurances will not pay for a second-generation TKI, in which case I don’t put up much resistance and just go with the use of imatinib, either generic or branded, because I can easily – within a month say – if a patient is not responding or not tolerating it, get the treatment if I really want a second-generation TKI. Now, for the second-generation TKI my preference has been dasatinib. It’s just that, certainly when nilotinib came out close to the same time, and nilotinib has these restrictions regarding not being able to take with meals. And so, it’s an inconvenient drug to take. So, I think for that reason dasatinib has been my favored drug. Now, bosutinib came out quite a while later and it gained some perception that it was not as good as the other two, because the company had to do a second trial to show it was even effective. The first trial failed. I think people are kind of slowly warming up to bosutinib, but it’s still not the preferred first-line.

Accelerated-phase patients we treat fairly similarly [to chronic-phase]. Blast-phase patients, we know that these patients, even if they have a response to treatment, are going to be transient and so the goal of therapy there, in a transplant-eligible patient, is to take the patient to transplant. In the short-term they get either TKI or if the TKIs are not working then we give them AML-like chemotherapy or if they have got lymphoblastitis then ALL-like chemotherapy.

I think that Iclusig obviously has serious cardiovascular morbidities associated with it, so a patient who has, say unstable angina, or has recently had a stroke, I probably would be reluctant to give the drug to them. Now, this OPTIC trial [has shown] that starting at a high dose and reducing the dose once the patient achieves the level of response is probably safe… I think that will be the way one will use Iclusig. Not that it will change when I use Iclusig, but when the decision has been made to use Iclusig, one will follow the guidelines.