BSH 2024 | The management of moderate to severe anemia in patients with myelofibrosis
Mary Frances McMullin, MD, Queen’s University, Belfast, UK, provides insight into managing moderate to severe anemia in patients with myelofibrosis (MF). It is crucial that clinicians investigate the cause of the anemia and measure erythropoietin levels prior to initiating treatment. The anemia can then be managed with erythropoiesis-stimulating agents (ESAs) or several other agents, such as danazol. Prof. McMullin also emphasizes that ruxolitinib, the frontline treatment option for MF, may decrease hemoglobin levels and worsen anemia; therefore, the novel agent momelotinib will likely become the first choice when treating patients. This interview took place at the 64th Annual Scientific Meeting of the British Society for Haematology (BSH) Congress in Liverpool, UK.
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Transcript (edited for clarity)
So, anemia and myelofibrosis is a difficult issue to tackle. Patients should be investigated first, trying to find out if there are any causes for the anemia, hematinic deficiency, autoimmune disease, etc., etc. because many of these can contribute. And having made sure that there’s nothing else apart from the myelofibrosis that’s contributing to the anemia, the issues then are how do you manage it? And the first thing that you can do is give erythropoietin stimulating agents, having first measured the erythropoietin level because we want to be sure to see that these patients have a low or normal erythropoietin level...
So, anemia and myelofibrosis is a difficult issue to tackle. Patients should be investigated first, trying to find out if there are any causes for the anemia, hematinic deficiency, autoimmune disease, etc., etc. because many of these can contribute. And having made sure that there’s nothing else apart from the myelofibrosis that’s contributing to the anemia, the issues then are how do you manage it? And the first thing that you can do is give erythropoietin stimulating agents, having first measured the erythropoietin level because we want to be sure to see that these patients have a low or normal erythropoietin level. If they have a very high erythropoietin level, then it’s pointless giving them ESAs. And then they can be given ESAs to see if they respond in order to put their hemoglobin up. Dosing is fairly standard, and they should be given a trial of that for up to 12 weeks. It may work, it may not work, and other things that then can be tried are things like danazol and then there are a number of other agents: steroids, IMiDs, and some drugs that are not widely available in the UK but that may be helpful in managing the anemia. However, you may be left with a patient with anemia and myelofibrosis. And the issue then is what do you do from the point of view of treatment? The first line agent which we widely use is ruxolitinib, which often makes patients drop their hemoglobin, makes them more anemic, and this now… the hemoglobin may stabilize, so you can try that, but it may make the anemia worse. So then the new kid on the block, so to speak, is momelotinib, which is now licensed. It has a different mechanism of action, and so that is an ACVR1 inhibitor and, therefore, interferes with hepcidin and the hemoglobin may then come up. So in a patient who is anemic with myelofibrosis, momelotinib is probably now the first line choice in order to treat these patients with myelofibrosis and therefore control their spleen, their symptoms, etc., but also may improve their hemoglobin and may even make them transfusion-independent.
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Disclosures
Advisory Board: Novartis, BMS, GSK; Speaker Bureau: Novartis, GSK, Incyte; Clinical Trial Support: BMS.
