Difference between revisions of "Myelodysplastic syndrome"
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=Untreated= | =Untreated= | ||
− | ==Alemtuzumab== | + | ==Alemtuzumab (Campath)== |
''Indication: Intermediate-1 MDS (RAEB-I, RA, or RARS)'' | ''Indication: Intermediate-1 MDS (RAEB-I, RA, or RARS)'' | ||
===Regimen=== | ===Regimen=== | ||
− | *[[Alemtuzumab (Campath)]] 1 mg IV once on day 1; then 10 mg IV once | + | *[[Alemtuzumab (Campath)]] 1 mg IV once on day 1; then 10 mg IV once per day on days 2 to 11 |
− | |||
− | |||
Supportive Medications: | Supportive Medications: | ||
Line 20: | Line 18: | ||
*[[Ciprofloxacin (Cipro)]] dose/schedule not specified if ANC <500/uL | *[[Ciprofloxacin (Cipro)]] dose/schedule not specified if ANC <500/uL | ||
*Erythropoietin and [[Filgrastim (Neupogen)|G-CSF]] were permitted for severe anemia or neutropenia | *Erythropoietin and [[Filgrastim (Neupogen)|G-CSF]] were permitted for severe anemia or neutropenia | ||
+ | |||
+ | '''11-day course of therapy''' | ||
===References=== | ===References=== | ||
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==Antithymocyte globulin (ATG)== | ==Antithymocyte globulin (ATG)== | ||
===Regimen=== | ===Regimen=== | ||
− | *[[Antithymocyte globulin (ATG)]] 40 mg/kg IV over 4 | + | *[[Antithymocyte globulin (ATG)]] 40 mg/kg IV over 4 to 8 hours on days 1 to 4 |
− | *[[Prednisone (Sterapred)]] 1 mg/kg (minimum of 40 mg) PO on days 1 | + | *[[Prednisone (Sterapred)]] 1 mg/kg (minimum of 40 mg) PO on days 1 to 10, and then tapered to off during days 11 to 17 |
===References=== | ===References=== | ||
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==Azacitidine (Vidaza)== | ==Azacitidine (Vidaza)== | ||
===Regimen #1, various=== | ===Regimen #1, various=== | ||
− | *[[Azacitidine (Vidaza)]] 75 mg/m2 SC or IV continuous infusion | + | *[[Azacitidine (Vidaza)]] 75 mg/m2 SC or IV continuous infusion on days 1 to 7 |
'''28-day cycles, given for at least 4 cycles, then depending on study, continued for 3 cycles beyond complete remission, or if there was progressive disease or unacceptable toxicity''' | '''28-day cycles, given for at least 4 cycles, then depending on study, continued for 3 cycles beyond complete remission, or if there was progressive disease or unacceptable toxicity''' | ||
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''Intended to be used for low-risk MDS patients who are symptomatic or intolerant to erythropoietin'' | ''Intended to be used for low-risk MDS patients who are symptomatic or intolerant to erythropoietin'' | ||
− | *[[Azacitidine (Vidaza)]] 75 mg/m2 SC | + | *[[Azacitidine (Vidaza)]] 75 mg/m2 SC once per day on days 1 to 5 |
− | |||
− | |||
Supportive medications: | Supportive medications: | ||
Line 52: | Line 50: | ||
* Erythropoiesis-stimulating agents were not allowed | * Erythropoiesis-stimulating agents were not allowed | ||
* Antimicrobial and antifungal prophylaxis (agents not specified) given if ANC < 500 | * Antimicrobial and antifungal prophylaxis (agents not specified) given if ANC < 500 | ||
+ | |||
+ | '''28-day cycles x 8 cycles''' | ||
===Regimen #3, Grövdal et al. 2010=== | ===Regimen #3, Grövdal et al. 2010=== | ||
''Intended to be used for high-risk MDS patients in remission after induction therapy'' | ''Intended to be used for high-risk MDS patients in remission after induction therapy'' | ||
− | *[[Azacitidine (Vidaza)]] 60 mg/m2 SC | + | *[[Azacitidine (Vidaza)]] 60 mg/m2 SC once per day on days 1 to 5 |
'''28-day cycles''' | '''28-day cycles''' | ||
Line 66: | Line 66: | ||
# Grövdal M, Karimi M, Khan R, Aggerholm A, Antunovic P, Astermark J, Bernell P, Engström LM, Kjeldsen L, Linder O, Nilsson L, Olsson A, Holm MS, Tangen JM, Wallvik J, Oberg G, Hokland P, Jacobsen SE, Porwit A, Hellström-Lindberg E. Maintenance treatment with azacytidine for patients with high-risk myelodysplastic syndromes (MDS) or acute myeloid leukaemia following MDS in complete remission after induction chemotherapy. Br J Haematol. 2010 Aug;150(3):293-302. doi: 10.1111/j.1365-2141.2010.08235.x. Epub 2010 May 20. [http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2141.2010.08235.x/full link to original article] '''contains verified protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/20497178 PubMed] | # Grövdal M, Karimi M, Khan R, Aggerholm A, Antunovic P, Astermark J, Bernell P, Engström LM, Kjeldsen L, Linder O, Nilsson L, Olsson A, Holm MS, Tangen JM, Wallvik J, Oberg G, Hokland P, Jacobsen SE, Porwit A, Hellström-Lindberg E. Maintenance treatment with azacytidine for patients with high-risk myelodysplastic syndromes (MDS) or acute myeloid leukaemia following MDS in complete remission after induction chemotherapy. Br J Haematol. 2010 Aug;150(3):293-302. doi: 10.1111/j.1365-2141.2010.08235.x. Epub 2010 May 20. [http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2141.2010.08235.x/full link to original article] '''contains verified protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/20497178 PubMed] | ||
# Filì C, Malagola M, Follo MY, Finelli C, Iacobucci I, Martinelli G, Cattina F, Clissa C, Candoni A, Fanin R, Gobbi M, Bocchia M, Defina M, Spedini P, Skert C, Manzoli L, Cocco L, Russo D. Prospective Phase II Study on 5-Days Azacitidine for Treatment of Symptomatic and/or Erythropoietin Unresponsive Patients with Low/INT-1-Risk Myelodysplastic Syndromes. Clin Cancer Res. 2013 May 22. [Epub ahead of print] [http://clincancerres.aacrjournals.org/content/19/12/3297.full link to original article] '''contains verified protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/23596104 PubMed] | # Filì C, Malagola M, Follo MY, Finelli C, Iacobucci I, Martinelli G, Cattina F, Clissa C, Candoni A, Fanin R, Gobbi M, Bocchia M, Defina M, Spedini P, Skert C, Manzoli L, Cocco L, Russo D. Prospective Phase II Study on 5-Days Azacitidine for Treatment of Symptomatic and/or Erythropoietin Unresponsive Patients with Low/INT-1-Risk Myelodysplastic Syndromes. Clin Cancer Res. 2013 May 22. [Epub ahead of print] [http://clincancerres.aacrjournals.org/content/19/12/3297.full link to original article] '''contains verified protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/23596104 PubMed] | ||
+ | |||
+ | ==Azacitidine & Lenalidomide== | ||
+ | |||
+ | [[Levels of Evidence]]: | ||
+ | <span | ||
+ | style="background:#EEEE00; | ||
+ | padding:3px 6px 3px 6px; | ||
+ | border-color:black; | ||
+ | border-width:2px; | ||
+ | border-style:solid;">Phase II</span> | ||
+ | |||
+ | ===Regimen=== | ||
+ | *[[Azacitidine (Vidaza)]] 75 mg/m2/day on days 1 to 5 | ||
+ | *[[Lenalidomide (Revlimid)]] 10mg PO once per day on days 1 to 21 | ||
+ | |||
+ | '''28-day cycles up to 7 cycles, with option to continue single agent azacitidine per MD discretion''' | ||
+ | |||
+ | ===References=== | ||
+ | # Sekeres MA, Tiu RV, Komrokji R, Lancet J, Advani AS, Afable M, Englehaupt R, Juersivich J, Cuthbertson D, Paleveda J, Tabarroki A, Visconte V, Makishima H, Jerez A, Paquette R, List AF, Maciejewski JP. Phase 2 study of the lenalidomide and azacitidine combination in patients with higher-risk myelodysplastic syndromes. Blood. 2012 Dec 13;120(25):4945-51. doi: 10.1182/blood-2012-06-434639. Epub 2012 Aug 22. [http://bloodjournal.hematologylibrary.org/content/120/25/4945.full link to original article] '''contains protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/22915641 PubMed] | ||
==Clofarabine (Clolar)== | ==Clofarabine (Clolar)== | ||
===Regimen #1, Faderl et al. 2010=== | ===Regimen #1, Faderl et al. 2010=== | ||
''Initial dose was too toxic; 20 mg/m2 was final dose level'' | ''Initial dose was too toxic; 20 mg/m2 was final dose level'' | ||
− | *[[Clofarabine (Clolar)]] 20 mg/m2 PO | + | *[[Clofarabine (Clolar)]] 20 mg/m2 PO once per day on days 1 to 5 |
− | |||
− | |||
Supportive medications: | Supportive medications: | ||
*"Supportive care included anti-infectious prophylaxis (eg, levaquin, valacyclovir, and itraconazole or voriconazole), hematopoietic growth factors, and transfusions as judged indicated by the treating physician." In order to decrease risk of liver function abnormalities, no antifungals were given on the days where clofarabine was given. | *"Supportive care included anti-infectious prophylaxis (eg, levaquin, valacyclovir, and itraconazole or voriconazole), hematopoietic growth factors, and transfusions as judged indicated by the treating physician." In order to decrease risk of liver function abnormalities, no antifungals were given on the days where clofarabine was given. | ||
+ | |||
+ | '''4 to 8 week cycles x up to 12 cycles''' | ||
===Regimen #2, Faderl et al. 2012=== | ===Regimen #2, Faderl et al. 2012=== | ||
''Lower dose was less toxic; clinical activity was comparable'' | ''Lower dose was less toxic; clinical activity was comparable'' | ||
− | *[[Clofarabine (Clolar)]] 15 mg/m2 or 30 mg/m2 IV over 1 hour | + | *[[Clofarabine (Clolar)]] 15 mg/m2 or 30 mg/m2 IV over 1 hour once per day on days 1 to 5 |
− | |||
− | |||
Supportive medications: | Supportive medications: | ||
*"Supportive care measures such as antibiotic prophylaxis (eg, levofloxacin, valacyclovir, and itraconazole or voriconazole), hematopoietic growth factors, and transfusions were provided as necessitated for optimal medical care of the patients." In order to decrease risk of liver function abnormalities, no antifungals were given on the days where clofarabine was given. | *"Supportive care measures such as antibiotic prophylaxis (eg, levofloxacin, valacyclovir, and itraconazole or voriconazole), hematopoietic growth factors, and transfusions were provided as necessitated for optimal medical care of the patients." In order to decrease risk of liver function abnormalities, no antifungals were given on the days where clofarabine was given. | ||
+ | |||
+ | '''4 to 8 week cycles x up to 12 cycles''' | ||
===References=== | ===References=== | ||
Line 92: | Line 111: | ||
==Cyclosporine modified (Neoral)== | ==Cyclosporine modified (Neoral)== | ||
===Regimen=== | ===Regimen=== | ||
− | *[[Cyclosporine modified (Neoral)]] 5 | + | *[[Cyclosporine modified (Neoral)]] 5 to 6 mg/kg/day, divided into two equal doses PO BID, adjusted to maintain therapeutic cyclosporine level of 100 to 300 ng/mL |
===References=== | ===References=== | ||
Line 99: | Line 118: | ||
==Decitabine (Dacogen)== | ==Decitabine (Dacogen)== | ||
− | |||
− | |||
− | |||
− | |||
− | |||
===Regimen #1, Kantarjian et al. 2007=== | ===Regimen #1, Kantarjian et al. 2007=== | ||
*[[Decitabine (Dacogen)]] 20 mg/m2/day divided into 2 SC doses per day on days 1 to 5 | *[[Decitabine (Dacogen)]] 20 mg/m2/day divided into 2 SC doses per day on days 1 to 5 | ||
Line 128: | Line 142: | ||
border-style:solid;">Phase II</span> | border-style:solid;">Phase II</span> | ||
− | *[[Decitabine (Dacogen)]] 20 mg/m2 SC | + | *[[Decitabine (Dacogen)]] 20 mg/m2 SC once per day on days 1 to 3 |
'''28-day cycles +/- 3 days x up to 12 months''' | '''28-day cycles +/- 3 days x up to 12 months''' | ||
Line 144: | Line 158: | ||
'''28-day cycles +/- 3 days x up to 12 months''' | '''28-day cycles +/- 3 days x up to 12 months''' | ||
+ | |||
+ | ===Regimen #6=== | ||
+ | *[[Decitabine (Dacogen)]] 20 mg/m2 IV over 1 hour once per day on days 1 to 5 | ||
+ | |||
+ | '''28-day cycles''' | ||
===References=== | ===References=== | ||
Line 151: | Line 170: | ||
# Garcia-Manero G, Jabbour E, Borthakur G, Faderl S, Estrov Z, Yang H, Maddipoti S, Godley LA, Gabrail N, Berdeja JG, Nadeem A, Kassalow L, Kantarjian H. Randomized Open-Label Phase II Study of Decitabine in Patients With Low- or Intermediate-Risk Myelodysplastic Syndromes. J Clin Oncol. 2013 Jun 3. [Epub ahead of print] [http://jco.ascopubs.org/content/31/20/2548.full link to original article] '''contains verified protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/23733767 PubMed] | # Garcia-Manero G, Jabbour E, Borthakur G, Faderl S, Estrov Z, Yang H, Maddipoti S, Godley LA, Gabrail N, Berdeja JG, Nadeem A, Kassalow L, Kantarjian H. Randomized Open-Label Phase II Study of Decitabine in Patients With Low- or Intermediate-Risk Myelodysplastic Syndromes. J Clin Oncol. 2013 Jun 3. [Epub ahead of print] [http://jco.ascopubs.org/content/31/20/2548.full link to original article] '''contains verified protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/23733767 PubMed] | ||
− | ==Lenalidomide | + | ==Epoetin alfa & Lenalidomide== |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
[[Levels of Evidence]]: | [[Levels of Evidence]]: | ||
Line 172: | Line 181: | ||
===Regimen=== | ===Regimen=== | ||
− | *[[Lenalidomide (Revlimid)]] | + | *[[Lenalidomide (Revlimid)]] 10 to 15 mg PO once per day |
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
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− | |||
'''For 16 weeks; erythroid nonresponders or those with relapsed anemia then offered combined treatment:''' | '''For 16 weeks; erythroid nonresponders or those with relapsed anemia then offered combined treatment:''' | ||
− | |||
*[[Epoetin alfa (Procrit)]] 40,000 units SC weekly | *[[Epoetin alfa (Procrit)]] 40,000 units SC weekly | ||
+ | *[[Lenalidomide (Revlimid)]] 10 to 15 mg PO once per day | ||
'''Continue until treatment failure or limiting toxicity''' | '''Continue until treatment failure or limiting toxicity''' | ||
Line 202: | Line 192: | ||
===References=== | ===References=== | ||
# Komrokji RS, Lancet JE, Swern AS, Chen N, Paleveda J, Lush R, Saba HI, List AF. Combined treatment with lenalidomide and epoetin alfa in lower-risk patients with myelodysplastic syndrome. Blood. 2012 Oct 25;120(17):3419-24. doi:10.1182/blood-2012-03-415661. Epub 2012 Aug 30. [http://bloodjournal.hematologylibrary.org/content/120/17/3419.long link to original article] '''contains protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/22936658 PubMed] | # Komrokji RS, Lancet JE, Swern AS, Chen N, Paleveda J, Lush R, Saba HI, List AF. Combined treatment with lenalidomide and epoetin alfa in lower-risk patients with myelodysplastic syndrome. Blood. 2012 Oct 25;120(17):3419-24. doi:10.1182/blood-2012-03-415661. Epub 2012 Aug 30. [http://bloodjournal.hematologylibrary.org/content/120/17/3419.long link to original article] '''contains protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/22936658 PubMed] | ||
+ | |||
+ | ==Lenalidomide (Revlimid)== | ||
+ | ===Regimen=== | ||
+ | *[[Lenalidomide (Revlimid)]] 10 mg PO once per day | ||
+ | |||
+ | ===References=== | ||
+ | # List A, Kurtin S, Roe DJ, Buresh A, Mahadevan D, Fuchs D, Rimsza L, Heaton R, Knight R, Zeldis JB. Efficacy of lenalidomide in myelodysplastic syndromes. N Engl J Med. 2005 Feb 10;352(6):549-57. [http://www.nejm.org/doi/full/10.1056/NEJMoa041668 link to original article] [http://www.ncbi.nlm.nih.gov/pubmed/15703420 PubMed] | ||
+ | # Tefferi A, Cortes J, Verstovsek S, Mesa RA, Thomas D, Lasho TL, Hogan WJ, Litzow MR, Allred JB, Jones D, Byrne C, Zeldis JB, Ketterling RP, McClure RF, Giles F, Kantarjian HM. Lenalidomide therapy in myelofibrosis with myeloid metaplasia. Blood. 2006 Aug 15;108(4):1158-64. Epub 2006 Apr 11. [http://bloodjournal.hematologylibrary.org/content/108/4/1158.long link to original article] '''contains protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/16609064 PubMed] | ||
+ | # List A, Dewald G, Bennett J, Giagounidis A, Raza A, Feldman E, Powell B, Greenberg P, Thomas D, Stone R, Reeder C, Wride K, Patin J, Schmidt M, Zeldis J, Knight R; Myelodysplastic Syndrome-003 Study Investigators. Lenalidomide in the myelodysplastic syndrome with chromosome 5q deletion. N Engl J Med. 2006 Oct 5;355(14):1456-65. [http://www.nejm.org/doi/full/10.1056/NEJMoa061292 link to original article] '''contains protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/17021321 PubMed] | ||
+ | # Raza A, Reeves JA, Feldman EJ, Dewald GW, Bennett JM, Deeg HJ, Dreisbach L, Schiffer CA, Stone RM, Greenberg PL, Curtin PT, Klimek VM, Shammo JM, Thomas D, Knight RD, Schmidt M, Wride K, Zeldis JB, List AF. Phase 2 study of lenalidomide in transfusion-dependent, low-risk, and intermediate-1 risk myelodysplastic syndromes with karyotypes other than deletion 5q. Blood. 2008 Jan 1;111(1):86-93. Epub 2007 Sep 24. [http://bloodjournal.hematologylibrary.org/content/111/1/86.long link to original article] '''contains protocol''' [http://www.ncbi.nlm.nih.gov/pubmed/17893227 PubMed] |
Revision as of 20:48, 8 November 2013
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Untreated
Alemtuzumab (Campath)
Indication: Intermediate-1 MDS (RAEB-I, RA, or RARS)
Regimen
- Alemtuzumab (Campath) 1 mg IV once on day 1; then 10 mg IV once per day on days 2 to 11
Supportive Medications:
- Pentamidine (Nebupent) dose not specified INH monthly for at least 6 months for PCP prophylaxis
- Valacyclovir (Valtrex) dose/schedule not specified until CD4 count >200/uL
- Ciprofloxacin (Cipro) dose/schedule not specified if ANC <500/uL
- Erythropoietin and G-CSF were permitted for severe anemia or neutropenia
11-day course of therapy
References
- Sloand EM, Olnes MJ, Shenoy A, Weinstein B, Boss C, Loeliger K, Wu CO, More K, Barrett AJ, Scheinberg P, Young NS. Alemtuzumab treatment of intermediate-1 myelodysplasia patients is associated with sustained improvement in blood counts and cytogenetic remissions. J Clin Oncol. 2010 Dec 10;28(35):5166-73. doi:10.1200/JCO.2010.29.7010. Epub 2010 Nov 1. link to original article contains verified protocol PubMed
Antithymocyte globulin (ATG)
Regimen
- Antithymocyte globulin (ATG) 40 mg/kg IV over 4 to 8 hours on days 1 to 4
- Prednisone (Sterapred) 1 mg/kg (minimum of 40 mg) PO on days 1 to 10, and then tapered to off during days 11 to 17
References
- Molldrem JJ, Caples M, Mavroudis D, Plante M, Young NS, Barrett AJ. Antithymocyte globulin for patients with myelodysplastic syndrome. Br J Haematol. 1997 Dec;99(3):699-705. PubMed
- Molldrem JJ, Leifer E, Bahceci E, Saunthararajah Y, Rivera M, Dunbar C, Liu J, Nakamura R, Young NS, Barrett AJ. Antithymocyte globulin for treatment of the bone marrow failure associated with myelodysplastic syndromes. Ann Intern Med. 2002 Aug 6;137(3):156-63. link to original article contains protocol PubMed
- Steensma DP, Dispenzieri A, Moore SB, Schroeder G, Tefferi A. Antithymocyte globulin has limited efficacy and substantial toxicity in unselected anemic patients with myelodysplastic syndrome. Blood. 2003 Mar 15;101(6):2156-8. Epub 2002 Oct 31. link to original article contains protocol PubMed
- Sloand EM, Wu CO, Greenberg P, Young N, Barrett J. Factors affecting response and survival in patients with myelodysplasia treated with immunosuppressive therapy. J Clin Oncol. 2008 May 20;26(15):2505-11. Epub 2008 Apr 14. link to original article PubMed
Azacitidine (Vidaza)
Regimen #1, various
- Azacitidine (Vidaza) 75 mg/m2 SC or IV continuous infusion on days 1 to 7
28-day cycles, given for at least 4 cycles, then depending on study, continued for 3 cycles beyond complete remission, or if there was progressive disease or unacceptable toxicity
Regimen #2, Fili et al. 2013
Intended to be used for low-risk MDS patients who are symptomatic or intolerant to erythropoietin
- Azacitidine (Vidaza) 75 mg/m2 SC once per day on days 1 to 5
Supportive medications:
- G-CSF or GM-CSF was allowed if ANC < 200 and/or systemic infection
- Erythropoiesis-stimulating agents were not allowed
- Antimicrobial and antifungal prophylaxis (agents not specified) given if ANC < 500
28-day cycles x 8 cycles
Regimen #3, Grövdal et al. 2010
Intended to be used for high-risk MDS patients in remission after induction therapy
- Azacitidine (Vidaza) 60 mg/m2 SC once per day on days 1 to 5
28-day cycles
References
- Silverman LR, Demakos EP, Peterson BL, Kornblith AB, Holland JC, Odchimar-Reissig R, Stone RM, Nelson D, Powell BL, DeCastro CM, Ellerton J, Larson RA, Schiffer CA, Holland JF. Randomized controlled trial of azacitidine in patients with the myelodysplastic syndrome: a study of the cancer and leukemia group B. J Clin Oncol. 2002 May 15;20(10):2429-40. link to original article contains protocol PubMed
- Silverman LR, McKenzie DR, Peterson BL, Holland JF, Backstrom JT, Beach CL, Larson RA; Cancer and Leukemia Group B. Further analysis of trials with azacitidine in patients with myelodysplastic syndrome: studies 8421, 8921, and 9221 by the Cancer and Leukemia Group B. J Clin Oncol. 2006 Aug 20;24(24):3895-903. link to original article contains protocol PubMed
- Fenaux P, Mufti GJ, Hellstrom-Lindberg E, Santini V, Finelli C, Giagounidis A, Schoch R, Gattermann N, Sanz G, List A, Gore SD, Seymour JF, Bennett JM, Byrd J, Backstrom J, Zimmerman L, McKenzie D, Beach C, Silverman LR; International Vidaza High-Risk MDS Survival Study Group. Efficacy of azacitidine compared with that of conventional care regimens in the treatment of higher-risk myelodysplastic syndromes: a randomised, open-label, phase III study. Lancet Oncol. 2009 Mar;10(3):223-32. Epub 2009 Feb 21. link to original article contains protocol PubMed
- Grövdal M, Karimi M, Khan R, Aggerholm A, Antunovic P, Astermark J, Bernell P, Engström LM, Kjeldsen L, Linder O, Nilsson L, Olsson A, Holm MS, Tangen JM, Wallvik J, Oberg G, Hokland P, Jacobsen SE, Porwit A, Hellström-Lindberg E. Maintenance treatment with azacytidine for patients with high-risk myelodysplastic syndromes (MDS) or acute myeloid leukaemia following MDS in complete remission after induction chemotherapy. Br J Haematol. 2010 Aug;150(3):293-302. doi: 10.1111/j.1365-2141.2010.08235.x. Epub 2010 May 20. link to original article contains verified protocol PubMed
- Filì C, Malagola M, Follo MY, Finelli C, Iacobucci I, Martinelli G, Cattina F, Clissa C, Candoni A, Fanin R, Gobbi M, Bocchia M, Defina M, Spedini P, Skert C, Manzoli L, Cocco L, Russo D. Prospective Phase II Study on 5-Days Azacitidine for Treatment of Symptomatic and/or Erythropoietin Unresponsive Patients with Low/INT-1-Risk Myelodysplastic Syndromes. Clin Cancer Res. 2013 May 22. [Epub ahead of print] link to original article contains verified protocol PubMed
Azacitidine & Lenalidomide
Levels of Evidence: Phase II
Regimen
- Azacitidine (Vidaza) 75 mg/m2/day on days 1 to 5
- Lenalidomide (Revlimid) 10mg PO once per day on days 1 to 21
28-day cycles up to 7 cycles, with option to continue single agent azacitidine per MD discretion
References
- Sekeres MA, Tiu RV, Komrokji R, Lancet J, Advani AS, Afable M, Englehaupt R, Juersivich J, Cuthbertson D, Paleveda J, Tabarroki A, Visconte V, Makishima H, Jerez A, Paquette R, List AF, Maciejewski JP. Phase 2 study of the lenalidomide and azacitidine combination in patients with higher-risk myelodysplastic syndromes. Blood. 2012 Dec 13;120(25):4945-51. doi: 10.1182/blood-2012-06-434639. Epub 2012 Aug 22. link to original article contains protocol PubMed
Clofarabine (Clolar)
Regimen #1, Faderl et al. 2010
Initial dose was too toxic; 20 mg/m2 was final dose level
- Clofarabine (Clolar) 20 mg/m2 PO once per day on days 1 to 5
Supportive medications:
- "Supportive care included anti-infectious prophylaxis (eg, levaquin, valacyclovir, and itraconazole or voriconazole), hematopoietic growth factors, and transfusions as judged indicated by the treating physician." In order to decrease risk of liver function abnormalities, no antifungals were given on the days where clofarabine was given.
4 to 8 week cycles x up to 12 cycles
Regimen #2, Faderl et al. 2012
Lower dose was less toxic; clinical activity was comparable
- Clofarabine (Clolar) 15 mg/m2 or 30 mg/m2 IV over 1 hour once per day on days 1 to 5
Supportive medications:
- "Supportive care measures such as antibiotic prophylaxis (eg, levofloxacin, valacyclovir, and itraconazole or voriconazole), hematopoietic growth factors, and transfusions were provided as necessitated for optimal medical care of the patients." In order to decrease risk of liver function abnormalities, no antifungals were given on the days where clofarabine was given.
4 to 8 week cycles x up to 12 cycles
References
- Faderl S, Garcia-Manero G, Estrov Z, Ravandi F, Borthakur G, Cortes JE, O'Brien S, Gandhi V, Plunkett W, Byrd A, Kwari M, Kantarjian HM. Oral clofarabine in the treatment of patients with higher-risk myelodysplastic syndrome. J Clin Oncol. 2010 Jun 1;28(16):2755-60. doi: 10.1200/JCO.2009.26.3509. Epub 2010 Apr 26. link to original article contains verified protocol PubMed
- Faderl S, Garcia-Manero G, Jabbour E, Ravandi F, Borthakur G, Estrov Z, Gandhi V, Byrd AL, Kwari M, Cortes J, Kantarjian HM. A randomized study of 2 dose levels of intravenous clofarabine in the treatment of patients with higher-risk myelodysplastic syndrome. Cancer. 2012 Feb 1;118(3):722-8. doi:10.1002/cncr.26327. Epub 2011 Jul 12. link to original article contains verified protocol PubMed
Cyclosporine modified (Neoral)
Regimen
- Cyclosporine modified (Neoral) 5 to 6 mg/kg/day, divided into two equal doses PO BID, adjusted to maintain therapeutic cyclosporine level of 100 to 300 ng/mL
References
- Jonásova A, Neuwirtová R, Cermák J, Vozobulová V, Mociková K, Sisková M, Hochová I. Cyclosporin A therapy in hypoplastic MDS patients and certain refractory anaemias without hypoplastic bone marrow. Br J Haematol. 1998 Feb;100(2):304-9. link to original article contains protocol PubMed
- Sloand EM, Wu CO, Greenberg P, Young N, Barrett J. Factors affecting response and survival in patients with myelodysplasia treated with immunosuppressive therapy. J Clin Oncol. 2008 May 20;26(15):2505-11. Epub 2008 Apr 14. link to original article PubMed
Decitabine (Dacogen)
Regimen #1, Kantarjian et al. 2007
- Decitabine (Dacogen) 20 mg/m2/day divided into 2 SC doses per day on days 1 to 5
28-day cycles
Regimen #2, Kantarjian et al. 2007
- Decitabine (Dacogen) 10 mg/m2 IV over 1 hour once per day on days 1 to 10
28-day cycles
Regimen #3, Kantarjian et al. 2006; Rüter et al. 2006
- Decitabine (Dacogen) 15 mg/m2 IV over 3 hours every 8 hours on days 1 to 3
6-week cycles x up to 6 to 8 cycles
Regimen #4, Garcia-Manero et al. 2013
Level of Evidence: Phase II
- Decitabine (Dacogen) 20 mg/m2 SC once per day on days 1 to 3
28-day cycles +/- 3 days x up to 12 months
Regimen #5, Garcia-Manero et al. 2013
Level of Evidence: Phase II
- Decitabine (Dacogen) 20 mg/m2 SC weekly on days 1, 8, 15
28-day cycles +/- 3 days x up to 12 months
Regimen #6
- Decitabine (Dacogen) 20 mg/m2 IV over 1 hour once per day on days 1 to 5
28-day cycles
References
- Rüter B, Wijermans PW, Lübbert M. Superiority of prolonged low-dose azanucleoside administration? Results of 5-aza-2'-deoxycytidine retreatment in high-risk myelodysplasia patients. Cancer. 2006 Apr 15;106(8):1744-50. link to original article contains protocol PubMed
- Kantarjian H, Issa JP, Rosenfeld CS, Bennett JM, Albitar M, DiPersio J, Klimek V, Slack J, de Castro C, Ravandi F, Helmer R 3rd, Shen L, Nimer SD, Leavitt R, Raza A, Saba H. Decitabine improves patient outcomes in myelodysplastic syndromes: results of a phase III randomized study. Cancer. 2006 Apr 15;106(8):1794-803. link to original article contains protocol PubMed
- Kantarjian H, Oki Y, Garcia-Manero G, Huang X, O'Brien S, Cortes J, Faderl S, Bueso-Ramos C, Ravandi F, Estrov Z, Ferrajoli A, Wierda W, Shan J, Davis J, Giles F, Saba HI, Issa JP. Results of a randomized study of 3 schedules of low-dose decitabine in higher-risk myelodysplastic syndrome and chronic myelomonocytic leukemia. Blood. 2007 Jan 1;109(1):52-7. Epub 2006 Aug 1. link to original article contains protocol PubMed
- Garcia-Manero G, Jabbour E, Borthakur G, Faderl S, Estrov Z, Yang H, Maddipoti S, Godley LA, Gabrail N, Berdeja JG, Nadeem A, Kassalow L, Kantarjian H. Randomized Open-Label Phase II Study of Decitabine in Patients With Low- or Intermediate-Risk Myelodysplastic Syndromes. J Clin Oncol. 2013 Jun 3. [Epub ahead of print] link to original article contains verified protocol PubMed
Epoetin alfa & Lenalidomide
Levels of Evidence: Phase II
Regimen
- Lenalidomide (Revlimid) 10 to 15 mg PO once per day
For 16 weeks; erythroid nonresponders or those with relapsed anemia then offered combined treatment:
- Epoetin alfa (Procrit) 40,000 units SC weekly
- Lenalidomide (Revlimid) 10 to 15 mg PO once per day
Continue until treatment failure or limiting toxicity
References
- Komrokji RS, Lancet JE, Swern AS, Chen N, Paleveda J, Lush R, Saba HI, List AF. Combined treatment with lenalidomide and epoetin alfa in lower-risk patients with myelodysplastic syndrome. Blood. 2012 Oct 25;120(17):3419-24. doi:10.1182/blood-2012-03-415661. Epub 2012 Aug 30. link to original article contains protocol PubMed
Lenalidomide (Revlimid)
Regimen
- Lenalidomide (Revlimid) 10 mg PO once per day
References
- List A, Kurtin S, Roe DJ, Buresh A, Mahadevan D, Fuchs D, Rimsza L, Heaton R, Knight R, Zeldis JB. Efficacy of lenalidomide in myelodysplastic syndromes. N Engl J Med. 2005 Feb 10;352(6):549-57. link to original article PubMed
- Tefferi A, Cortes J, Verstovsek S, Mesa RA, Thomas D, Lasho TL, Hogan WJ, Litzow MR, Allred JB, Jones D, Byrne C, Zeldis JB, Ketterling RP, McClure RF, Giles F, Kantarjian HM. Lenalidomide therapy in myelofibrosis with myeloid metaplasia. Blood. 2006 Aug 15;108(4):1158-64. Epub 2006 Apr 11. link to original article contains protocol PubMed
- List A, Dewald G, Bennett J, Giagounidis A, Raza A, Feldman E, Powell B, Greenberg P, Thomas D, Stone R, Reeder C, Wride K, Patin J, Schmidt M, Zeldis J, Knight R; Myelodysplastic Syndrome-003 Study Investigators. Lenalidomide in the myelodysplastic syndrome with chromosome 5q deletion. N Engl J Med. 2006 Oct 5;355(14):1456-65. link to original article contains protocol PubMed
- Raza A, Reeves JA, Feldman EJ, Dewald GW, Bennett JM, Deeg HJ, Dreisbach L, Schiffer CA, Stone RM, Greenberg PL, Curtin PT, Klimek VM, Shammo JM, Thomas D, Knight RD, Schmidt M, Wride K, Zeldis JB, List AF. Phase 2 study of lenalidomide in transfusion-dependent, low-risk, and intermediate-1 risk myelodysplastic syndromes with karyotypes other than deletion 5q. Blood. 2008 Jan 1;111(1):86-93. Epub 2007 Sep 24. link to original article contains protocol PubMed