Maples, a clinical pharmacy specialist supervisor at Allegheny Health Network, explains that the first decision after diagnosis is no longer whether to use a TKI, but which one. Clinicians must also decide whether to pair it with chemotherapy, immunotherapy, steroids, or nothing at all. TKIs work better the earlier they’re started. Dasatinib and ponatinib (Iclusig; Takeda) have outperformed imatinib, and retrospective data increasingly favor ponatinib. She says this takes a shift in thinking for clinicians who know ponatinib as a later-line CML drug. Blinatumomab (Blincyto; Amgen) now makes chemotherapy-free, long-term remission a realistic goal for some patients.
Griffin, an associate clinical professor and hematology and stem cell transplant pharmacist at the University of California, Irvine, describes the phase 3 GIMEMA ALL2820 trial (NCT04722848). The trial compared ponatinib plus blinatumomab with imatinib plus chemotherapy. He says the results lead many clinicians to ask whether every patient with Ph+ ALL still needs a transplant. Maples notes that the comparator arm used imatinib rather than ponatinib. Even so, she says the combination is a viable option, especially for patients who may never be transplant candidates.
Griffin then asks what pharmacists bring to treatment selection. Maples says she often slows the team down when a new regimen generates excitement, to check whether it fits the patient. Age and comorbidities matter most. Patients older than 60 tend to have more adverse effects, and patients with significant cardiac comorbidities were often excluded from trials because of ponatinib’s arterial risks. She finds drug interactions usually manageable through coordination with other specialties. Financial and social factors can also make a regimen less suitable.
Our next episode, “Ponatinib in Ph+ ALL: Translating Clinical Value Into Treatment Decisions,” turns to how pharmacists confirm that ponatinib is right for a patient and get treatment started.
