ABSTRACT: The introduction of the tyrosine kinase inhibitor (TKI) imatinib(Drug information on imatinib) (Gleevec) into clinical practice resulted in a very dramatic prolongation of survival for most, but not all, patients with chronic myeloid leukemia in chronic phase (CML-CP). A leukemia with a median survival of about 5 years was transformed into one for which the survival in many cases promises to be comparable to that of normal persons of similar age. The more recently available TKIs, namely nilotinib(Drug information on nilotinib) (Tasigna) and dasatinib(Drug information on dasatinib) (Sprycel), produce more rapid responses but have not yet shown any overall survival advantage compared with long-term administration of imatinib. They are, however, useful in treating imatinib intolerance or resistance. There are currently two choices for initial treatment of CML-CP: (1) starting all new patients on imatinib and changing to a second-generation TKI in those who fail or who are predicted to fare badly, or (2) starting all new patients on a second-generation TKI. This choice may be based primarily on considerations of cost or possible side effects.
The management of patients with newly diagnosed chronic myeloid leukemia (CML) in chronic phase (CML-CP) has changed very fundamentally over the past 10 years. Until 1998 there was little dispute that a new patient should be offered treatment by allogeneic stem cell transplantation (allo-SCT) if he or she was relatively young and had a suitable human leukocyte antigen (HLA)-matched sibling donor. If there were no sibling donors, then efforts were made to identify an HLA-matched family member or an unrelated volunteer from the general public. Patients not eligible for treatment by allo-SCT usually received interferon alfa or hydroxyurea, but the median expectation of life ranged between 3 and 6 years. In the 1990s, Druker, working in conjunction with Ciba-Geigy (now Novartis) in Switzerland, developed the 2-phenylaminopyrimidine derivative tyrosine kinase inhibitor (TKI) imatinib mesylate (Gleevec), now referred to just as imatinib, which specifically targeted the BCR-ABL1 oncoprotein characteristic of CML and selectively killed CML cells in vitro.[1,2] Imatinib was first used in the clinic in 1998, and it soon became clear that this agent produced impressive cytogenetic responses in patients with interferon-resistant CML. This led rapidly to the initiation in 2000 of the International Randomized Study of Interferon vs STI571 (IRIS study), in which 1,106 CML-CP patients from 15 countries were recruited over a 6-month period and randomly assigned to receive either imatinib or interferon + cytarabine(Drug information on cytarabine) in a 1:1 ratio. The early results of this study were reported first in 2003 and have been updated at intervals since then.[5,6] They showed that imatinib produced an extremely high cumulative incidence of complete cytogenetic responses, and the patients who experienced a complete response had a mortality at 8 years of 16%. The crossover or drop-out of patients from the interferon/cytarabine arm was so great that the comparison component of the study rapidly became inevaluable, but the long-term survival of patients treated in the imatinib arm was of course substantially better than would have been expected based on treatment with interferon in an earlier era.
In the past decade, the notion of treating CML by targeting the BCR-ABL1 oncoprotein has been developed further. Four new TKIs, namely dasatinib (Sprycel), nilotinib (Tasigna), bosutinib (Bosulif), and ponatinib, have been introduced; all have demonstrable efficacy in treating patients whose leukemia has proved resistant to imatinib. The first three agents, dasatinib, nilotinib, and bosutinib, have been compared prospectively with imatinib in newly diagnosed patients, and all clearly produced more rapid responses than imatinib at the dose levels employed.[7-9] A phase III study of ponatinib compared with imatinib is just starting, and the same may prove to be true for ponatinib. The newer TKIs are, however, generally more expensive than imatinib, and when the patents on imatinib expire and generic versions become available, the difference in cost may increase still further. The critical question is therefore: Is it reasonable to start all new CML patients on treatment with imatinib alone and continue the drug indefinitely in those who fare well, or should one start treatment with one of the newer agents or possibly with imatinib in combination with another anti-CML agent in order to secure the best possible outcome for an individual patient?
TKIs: Side-Effect Overview
Side effects differ from drug to drug, but for TKIs it is possible to define a drug class side-effect profile; this includes myelosuppression (the main side effect), fatigue, fluid retention, hepatotoxicity, gastrointestinal disturbances, myalgias, arthralgias, rashes, prolongation of the QTc interval, hypocalcemia, hypophosphatemia, and increases in amylase and lipase levels. All four TKIs can cause these effects, but their relative frequencies differ: for example, facial edema is very common with imatinib but rare with dasatinib, whereas rashes are relatively common with nilotinib but less prominent with dasatinib (Table 1).
Imatinib was the first TKI. Typically it is given once a day at a standardized dose of 400 mg, although the maximum tolerated dose was never formally established. Some studies have tested higher doses—eg, 600 or 800 mg daily.[10,11-13] Imatinib is normally given with food to prevent or minimize nausea.
We have more than 14 years of experience with imatinib, and 12 years of experience with imatinib as first-line therapy for CML. The drug is safe. It has been taken by many thousands of patients, and the side-effect profile is well established. Nausea, myalgia, arthralgia, and fluid retention are seen far more frequently in patients receiving imatinib than in those treated with other TKIs. Nausea and fluid retention can be easily managed, but arthralgia and myalgia may persist as late side effects in a minority of patients despite optimal support.
Approximately 70% of patients who receive imatinib as first-line therapy achieve a complete cytogenetic response (CCyR) by 12 months, and 80% do so by 5 years. In a series of 282 patients treated at Hammersmith Hospital in London, the 8-year probability of overall survival on an intention-to-treat basis was 84%, the 8-year probability of being alive and in CCyR was 77%, and the 8-year probability of imatinib failure–free survival was 50%, indicating that although the majority of patients who begin imatinib therapy fare well, a significant proportion need a change of therapy on account of unsatisfactory response or side effects.
Attempts have been made to start treatment for CML-CP by combining imatinib with other agents, notably with interferon alfa. In two studies, this combination yielded better shortterm results than the use of imatinib alone, but there was no difference in progression-free or overall survival.[13,15] In one study, there was no demonstrable difference between the regimen that included interferon and the regimen that did not include it. Thus, the suggestion that interferon together with imatinib might be the best initial therapy for CML is so far unproved.
The obvious advantages of imatinib are that it is the only drug with which we have long-term (>10 years) experience, its side-effect profile is well known, and in most countries it is the least expensive of the available TKIs. Conversely, imatinib probably induces a higher proportion of insidious low-grade side effects (eg, muscle cramps) than nilotinib or dasatinib. At a standard dosage, the proportion of patients who achieve CCyR by 1 year is lower with imatinib than with nilotinib or dasatinib.
Nilotinib is a BCR-ABL1 inhibitor that was rationally designed to be more potent and more selective than imatinib. Until recently it had been used, for the most part quite successfully, as a second-line agent; it is now approved for first-line use at a dosage of 300 mg bid.
A number of studies report the use of nilotinib in patients deemed to be either refractory to or intolerant of imatinib (or both).[17-19] The 2-year incidence of CCyR in such patients has been on the order of 40%, which is generally consistent with the conclusion that nilotinib can “rescue” a proportion of the patients who fail imatinib. This initial experience with the use of nilotinib led to the design of a prospective study, the Evaluating Nilotinib Efficacy and Safety in clinical Trials of newly diagnosed (Philadelphia chromosome [Ph]+ CML) patients (ENESTnd) trial, in which 846 previously untreated patients were randomly assigned to receive imatinib, 400 mg once daily; nilotinib, 300 mg twice daily; or nilotinib, 400 mg twice daily. As a consequence of this study, the recommended dosage for newly diagnosed patients was specified as 300 mg twice daily. Perhaps the most important result has been that by 1 year the cumulative incidence of CCyR was 15% higher in the patients receiving nilotinib than in imatinib controls. Furthermore, patients receiving nilotinib had a much higher probability of achieving major molecular response (MMR). However, these superior response rates have not yet translated into any improvement in progression-free or overall survival.
Nilotinib is well tolerated; it causes less nausea, and fewer patients develop myalgias, arthralgias, or fluid retention than do patients receiving imatinib. It does produce rash or pruritus in the majority of patients; however, in most cases, these symptoms can be easily controlled with antihistamines or topical corticosteroids. Nilotinib is the most hepatotoxic of the four TKIs, although this hepatotoxicity is usually limited to a mild increase in transaminase levels that does not require action. Severe toxic hepatitis is rare. Nilotinib has been associated with progressive peripheral arterial occlusive disease, but this seems to be rare. Nilotinib causes an increase in the bilirubin level in the majority of patients, but this seldom requires any action.
Nilotinib is thus preferable to imatinib, since a higher proportion of patients achieve CCyR by 1 year. It is well tolerated and indeed has a better side-effect profile than imatinib if one excludes the rash. However, the posology is quite complicated because the drug has a short half-life. It is given every 12 hours, and patients have to fast for 2 hours before taking it and for 1 hour afterwards. In the majority of countries, nilotinib is significantly more expensive than imatinib.