Hughes Timothy, White Deborah
1South Australian Health and Medical Research Institute, SA Pathology, and University of Adelaide, Adelaide, Australia.
Hematology Am Soc Hematol Educ Program. 2013;2013:168-75. doi: 10.1182/asheducation-2013.1.168.
With the approval in many countries of nilotinib and dasatinib for frontline therapy in chronic myeloid leukemia, clinicians now have to make a difficult choice. Because none of the 3 available tyrosine kinase inhibitors (TKIs) have shown a clear survival advantage, they all represent reasonable choices. However, in individual patients, the case may be stronger for a particular TKI. In the younger patient, in whom the prospect of eventually achieving treatment-free remission is likely to be of great importance, dasatinib or nilotinib may be preferred, although their advantage over imatinib in this setting remains to be proven. In patients with a higher risk of transformation (which is currently based on prognostic scoring), the more potent TKIs may be preferred because they appear to be more effective at reducing the risk of transformation to BC. However, imatinib still represents an excellent choice for many chronic myeloid leukemia patients. All of these considerations need to be made in the context of the patient's comorbidities, which may lead to one or more TKIs being ruled out of contention. Whatever first choice of TKI is made, treatment failure or intolerance must be recognized early because a prompt switch to another TKI likely provides the best chance of achieving optimal response.
随着尼洛替尼和达沙替尼在许多国家被批准用于慢性髓性白血病的一线治疗，临床医生现在不得不做出艰难的选择。由于现有的3种酪氨酸激酶抑制剂（TKIs）均未显示出明显的生存优势，它们都代表了合理的选择。然而，对于个别患者而言，可能更倾向于选择某一种特定的TKI。对于年轻患者，最终实现无治疗缓解的前景可能非常重要，达沙替尼或尼洛替尼可能更受青睐，尽管它们在此情况下相对于伊马替尼的优势仍有待证实。对于具有较高转化风险的患者（目前基于预后评分），可能更倾向于选择效力更强的TKIs，因为它们似乎在降低转化为急变期（BC）的风险方面更有效。然而，伊马替尼对于许多慢性髓性白血病患者而言仍是一个绝佳的选择。所有这些考虑都需要结合患者的合并症来进行，合并症可能导致一种或多种TKIs被排除在选择范围之外。无论首次选择何种TKI，都必须尽早识别治疗失败或不耐受情况，因为及时换用另一种TKI可能为实现最佳反应提供最佳机会。
