Introduction
Ruxolitinib: general pharmacology
Myelofibrosis
Natural history and prognosis
Limitations of traditional therapies
Ruxolitinib for myelofibrosis
Efficacy
Effect on biomarkers
Survival and disease modification
Safety and tolerability
Percent of patients | Ruxolitinib (n = 155) | Placebo (n = 151) | ||
---|---|---|---|---|
All grades | Grade 3 or 4 | All grades | Grade 3 or 4 | |
Fatigue | 25.2 | 5.2 | 33.8 | 6.6 |
Diarrhea | 23.2 | 1.9 | 21.2 | 0 |
Peripheral edema | 18.7 | 0 | 22.5 | 1.3 |
Ecchymosis | 18.7 | 0 | 9.3 | 0 |
Dyspnea | 17.4 | 1.3 | 17.2 | 4.0 |
Dizziness | 14.8 | 0.6 | 6.6 | 0 |
Nausea | 14.8 | 0 | 19.2 | 0.7 |
Headache | 14.8 | 0 | 5.3 | 0 |
Constipation | 12.9 | 0 | 11.9 | 0 |
Vomiting | 12.3 | 0.6 | 9.9 | 0.7 |
Pain in extremity | 12.3 | 1.3 | 9.9 | 0 |
Insomnia | 11.6 | 0 | 9.9 | 0 |
Arthralgia | 11.0 | 1.9 | 8.6 | 0.7 |
Pyrexia | 11.0 | 0.6 | 7.3 | 0.7 |
Abdominal pain | 10.3 | 2.6 | 41.1 | 11.3 |
Percent of patients with any grade event (percent with grade 3 or 4 event) | COMFORT-I | COMFORT-II | ||
---|---|---|---|---|
Ruxolitinib (n = 155) | Placebo (n = 151) | Ruxolitinib (n = 146) | BAT (n = 73) | |
Anemia | 96.1 (45.2) | 86.8 (19.2) | 96 (42) | 94 (31) |
Thrombocytopenia | 69.7 (12.9) | 30.5 (1.3) | 68 (8) | 29 (7) |
Neutropenia | 18.7 (7.1) | 4.0 (2.0) | NR | NR |
Dose management to maximize efficacy and minimize treatment-related cytopenias
Population | Platelet count | Ruxolitinib starting dose |
---|---|---|
Myelofibrosis | ||
Regular starting doses based on platelet count | >200 × 109/L | 20 mg twice daily |
100 × 109 to 200 × 109/L | 15 mg twice daily | |
50 × 109 to <100 × 109/L | 5 mg twice daily | |
<50 × 109/L | Not recommended | |
Concomitant use of strong CYP3A4 inhibitors or fluconazole ≤200 mg | ≥100 × 109 to 200 × 109/L | 10 mg twice daily |
50 × 109 to <100 × 109/L | 5 mg twice daily | |
Fluconazole >200 mg | Any | Concomitant use not recommended |
Polycythemia vera | ||
Regular starting dose | Any | 10 mg twice daily |
Concomitant use of strong CYP3A4 inhibitors or fluconazole ≤200 mg | Any | 5 mg twice daily |
Fluconazole >200 mg | Any | Concomitant use not recommended |
Polycythemia vera
Clinical manifestation and prognosis
First-line therapy
Ruxolitinib for polycythemia vera
Efficacy
Safety and tolerability
Percent of patients with any grade event (percent with grade 3/grade 4 event) | Ruxolitinib (n = 110) | Standard therapy (n = 111) |
---|---|---|
Anemia | 43.6 (0.9/0.9) | 30.6 (0/0) |
Thrombocytopenia | 24.5 (4.5/0.9) | 18.9 (2.7/0.9) |
Lymphopenia | 43.6 (15.5/0.9) | 50.5 (16.2/1.8) |
Leukopenia | 9.1 (0.9/0) | 12.6 (1.8/0) |
Neutropenia | 1.8 (0/0.9) | 8.1 (0.9/0) |
Dosing
General safety considerations
Renal and hepatic impairment
Population | Platelet count | Ruxolitinib starting dose |
---|---|---|
Renal impairment | ||
MF: moderate (CrCl 30–59 mL/min) or severe (CrCl 15–29 mL/min) impairment | >150 × 109/L | No dose modification |
100 × 109 to 150 × 109/L | 10 mg twice daily | |
50 × 109 to <100 × 109/L | 5 mg daily | |
<50 × 109/L | Not recommended | |
PV: moderate or severe impairment | Any | 5 mg twice daily |
MF or PV: end-stage renal disease (CrCl < 15 mL/min) on dialysis | >200 × 109/L | 20 mg once after dialysis session |
100 × 109 to 200 × 109/L | 15 mg once after dialysis session | |
MF or PV: end-stage renal disease (CrCl < 15 mL/min) not requiring dialysis | Any | Not recommended |
Hepatic impairment (mild to severe) | ||
MF | >150 × 109/L | No dose modification |
100 × 109 to 150 × 109/L | 10 mg twice daily | |
50 × 109 to <100 × 109/L | 5 mg daily | |
<50 × 109/L | Not recommended | |
PV | Any | 5 mg twice daily |