Chronic myelogenous leukemia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamad Alkateb, MBBCh [2]

Overview

Medical therapies for chronic myelogenous leukemia (CML) include chemotherapy, stem cell transplant , and/or biological therapy. With improved understanding of the nature of the bcr-abl protein and its action as a tyrosine kinase, targeted therapies have been developed (the first of which was imatinib mesylate) which specifically inhibit the activity of theBCR-ABL protein. These tyrosine kinase inhibitors can induce complete remissions in chronic myelogenous leukemia, confirming the central importance of BCR-ABL as the cause of chronic myelogenous leukemia.[1]

PMID:24729196

PMID:26434969

Medical Therapy

Medical therapy depends on the phase of chronic myelogenous leukemia.

Chronic Phase

  • Targeted therapy[2]
  • Targeted therapy is the primary treatment for most people with chronic myelogenous leukemia in the chronic phase. The types of targeted therapy used are:
  • Standard first-line therapy
  • May be given as a first-line therapy
  • May also be used if a person cannot tolerate imatinib or the CML is resistant to imatinib
  • May be given as a first-line therapy
  • May also be used if a person cannot tolerate imatinib or the CML is resistant to imatinib
  • Stem cell transplant
  • Stem cell transplant may be offered for CML in the chronic phrase.
  • It is sometimes used as a primary treatment option for younger people who have an HLA-matched donor.
  • It is a treatment option for some people who do not achieve a complete response, develop resistance to or relapse with imatinib.
  • A reduced-intensity transplant may be an option for older people who may not tolerate a standard transplant.
  • The chemotherapy or radiation used to prepare for a stem cell transplant is less intense than that used for a standard allogeneic transplant.
  • Biological therapy
  • Biological therapy may be offered for chronic stage CML. Biological therapy can be used alone or in combination with chemotherapy.
  • The most common biological therapy used is interferon alfa (Intron A, Roferon A).
  • Interferon alfa may be used for people who cannot tolerate, or whose CML is resistant to, imatinib.
  • Chemotherapy
  • Chemotherapy may be offered for CML in the chronic phase. The types of chemotherapy used are:
  • Hydroxyurea (Hydrea, Apo-hydroxyurea, Gen-hydroxyurea)
  • Cytarabine (Cytosar)
  • May be used in combination with interferon alfa
  • Busulfan (Myleran [oral], Busulfex [intravenous])

Accelerated Phase

  • Stem cell transplant[2]
  • Allogeneic transplant.
  • Clinicians usually prefer that the leukemia returns to the chronic phase or is controlled before the transplant.
  • Sometimes an autologous transplant.
  • A reduced-intensity transplant may be an option for older people who may not tolerate a standard transplant.
  • The chemotherapy or radiation used to prepare for a stem cell transplant is less intense than that used for a standard allogeneic transplant.
  • Targeted therapy
  • Targeted therapy with a tyrosine kinase inhibitor may be offered during the accelerated phase of CML. For those already taking targeted therapy, the dose may be increased. The types of targeted therapy used are:
  • Biological therapy
  • Chemotherapy
  • Chemotherapy may be offered for CML in the accelerated phase. The types of chemotherapy used are:

Blast Phase

  • Targeted therapy[2]
  • Targeted therapy with a tyrosine kinase inhibitor may be offered for CML in the blast phase. For those already taking targeted therapy, the dose may be increased. The types of targeted therapy used are:
  • The most common drugs used when the leukemia cells look like AML include:
  • Cytarabine
  • HDAC (high-dose cytarabine)
  • An anthracycline, such as daunorubicin or doxorubicin
  • Tُhioguanine
  • Hydroxyurea
  • The most common drugs used when the leukemia cells look like ALL include the drugs listed above as well as:
  • There is increased risk of spread to the central nervous system (CNS) during the blast phase, so the following chemotherapy drugs may be given into the spinal fluid (intrathecal):
  • Stem cell transplant
  • Allogeneic stem cell transplant
  • Radiation therapy may be offered for blast phase CML for:

Relapsed or Refractory Chronic Myelogenous

  • Targeted therapy with a tyrosine kinase inhibitor may be offered for relapsed or refractory CML. For those already taking targeted therapy, the dose may be increased. The types of targeted therapy used are:

Supportive Therapy

  • Antibiotics and Antifungals
  • Blood products
  • Growth factors
  • Granulocyte colony-stimulating factors (G-CSF)

References


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