Optimization of therapeutic selection in myeloproliferative neoplasms

Ryan Haumschild, Doctor of Pharmacy, MS, MBA: As we continue our discussion of quality care for patients with NMP [myeloproliferative neoplasms], one of the things we always need to know is when to start and when to stop treatment. We’ve talked a bit about journey-focused and personalized care, but tell me a bit about when you’re part of the team and treating a patient with NMP. When do you want to start or stop treatment? What are some of these assessment timelines that you look at during this continuum of care?

Jeff A. Gilreath, Doctor of Pharmacy: Excellent question. For all our patients with NMP, we invite them back to the clinic every 3 months, so we have a fairly close follow-up. These elements may change over time. We don’t just deal with lab values, we want to treat the patient. It’s usually the symptoms that bring them on, sometimes it’s the routine elevation of white blood cells, red blood cells or platelets, but often it’s the symptoms.

In terms of initial treatment, it depends on the subtype of NMP we are dealing with. It is obviously very important to rule out other causes of high counts as well. We get a lot of referrals to our center for polycythemia vera, but it may be due to testosterone or other agents causing these numbers to increase. Similarly, we receive patients with iron deficiency anemia with thrombocytosis. We get these references where it is not AND [essential thrombocythemia]is iron deficiency anemia. We treat them with IV [intravenous] iron, and the platelet count returns to normal.

Regarding the start of treatment, we need a full diagnosis before even considering. Then we want to take a conservative approach to treating patients, making sure we define the symptoms they have and then targeting those symptoms, while reducing the risk of thrombosis. It will depend on whether you have myelofibrosis, polycythemia vera or ET. If you are otherwise asymptomatic, it is not always wrong to monitor the patient for several months and then bring them back. They can always call or come earlier to discuss whether to start treatment.

Conversely, when a treatment is stopped, there are several reasons. There may be adverse effects on the agent. This is a fairly clear indication to modify the dose or change agent if needed. What becomes less clear in patients with myelofibrosis is whether their numbers are increasing or decreasing due to drug toxicity causing cytopenia, or whether we are seeing transformation and worsening of the disease. Sometimes it’s hard to sort that out. We need other markers, such as splenomegaly or other signs of worsening disease burden. We will take all these elements into account when stopping treatment or changing treatment.

Ryan Haumschild, Doctor of Pharmacy, MS, MBA: It’s awesome. It’s very important to have some type of monitoring system, as well as having measures of success that say, “This patient is doing well” or “It’s time we started evaluating this next therapy. How do we ensure that we educate and prepare this patient? And then we move them on to the next part of their journey.

Transcripts edited for clarity.

Martin E. Berry