Tag Archives: anemia

Reevaluating Available Options for Anemia in Myelofibrosis

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February 6, 2025

By Targeted Oncology Staff
Fact checked by Jonah Feldman

DISCUSSION QUESTIONS

  • How do you monitor and manage anemia in patients with primary myelofibrosis prior to starting Janus kinase (JAK) inhibitor therapy?​
  • While receiving a JAK inhibitor therapy?

Andrew Kuykendall, MD: How do you monitor and manage anemia in patients with myelofibrosis even prior to starting a JAK inhibitor? If you’re initially evaluating someone, they come in with hemoglobin of 7 or 8 g/dL or something like that, how does that impact your thinking, and how do you work that up?

Lazaros Lekakis, MD: The first thing is to make sure that they don’t have something easily fixable [such as] iron, B12, or folate deficiency. Theoretically, if you don’t have any nutritional cause or any immune causes, you could use erythropoietin analogs, but they are very tricky because they don’t help with the spleen, at least in my experience, and they may increase the risk of clots. I try to avoid them if possible. If I have to start a JAK inhibitor, if they have symptoms, either I go away from ruxolitinib [Jakafi] or I start a low dose of ruxolitinib. Sometimes I use anabolic steroids and prednisone. We have the thalidomide/prednisone [regimen] that now is kind of forgotten about.

Kuykendall: Erythropoietin-stimulating agents [ESAs] are limited in what they do, and certainly not helping other aspects of the disease. You did mention one of my favorite regimens, thalidomide/prednisone, which is looked over a bit nowadays, but has quite a potential for efficacy in terms of improving hemoglobin. But it’s probably something that’s gone by the wayside in many practices.

Luis Sumoza, MD: As Dr Lekakis says, there are some other options that you can use. Danazol is sometimes something you can use perfectly in this patient population. From the JAK inhibitors, there is momelotinib [Ojjaara]. But a priority for me is to refer a patient for a stem cell transplant; when I was a fellow, we did the first allogeneic bone marrow transplant at the University of Illinois, Chicago, and it was a very nice experience.

Kuykendall: [Dr Lekakis] also mentioned steroids, [and we are] thinking about things like danazol, androgen derivatives. We saw from the MOMENTUM study [NCT04173494] looking at momelotinib that danazol is an active agent.1 It was a large, randomized trial, one of the first randomized trials with danazol. The focus there was on momelotinib, but there’s also a lot to learn about what danazol could do as well from that study.

Sumoza: You’re mainly talking about anemia here, and [if], the patient is not a candidate for a transplant or a clinical trial [there are] the data about navitoclax/ruxolitinib, which basically double the response and reduction of the spleen.2

Kuykendall: Yes, these emerging therapies to some degree may change how we approach this disease. But I think that with some of these older therapies, especially when you’re when you’re first talking about someone who’s coming in with anemia, you need to think about ESA, danazol, and thalidomide/prednisone.

I think that ESA is probably the most prominently used. How many of you are checking serum erythropoietin levels in these patients to assess their candidacy for ESAs, is that a common practice?

Mukesh Kumar, MD: Yes, I’m checking on all of my patients.

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Pacritinib and Momelotinib Display Positive Real-World Impact on Anemia and Transfusion Needs in Myelofibrosis

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December 12, 2024

Author(s): Kyle Doherty

Fact checked by: Caroline Seymour

Although long-term follow-up was limited, treatment with the JAK2 inhibitors pacritinib (Vonjo) and/or momelotinib (Ojjaara) led to favorable effects on anemia and transfusion requirements among patients with myelofibrosis, according to findings from a real-world study presented in a poster during the 2024 ASH Annual Meeting.1

Patients who received momelotinib (n = 32) had a median hemoglobin count of 8.7 g/dL (range, 6.5-1.2) at the start of therapy which increased to 9.0 g/dL after 3 months of treatment (P = .021). The median platelet count at the start of therapy was 141 x 109/L (range 15 x 109-504 x 109) and increased to 116 x 109/L after 3 months (P = .317). Patients required a mean of 1.9 red blood cell (RBC) units/month at the start of therapy and 0.47 units/month after 3 months of treatment (P = .015).

Patients treated with pacritinib (n = 27) had a median hemoglobin count of 8.5 g/dL (range, 6.9-12.9) at the start of treatment and a median count of 9.1 g/dL following 3 months of therapy (P = .402). The median platelet count at the start of therapy was 65 x 109/L(range, 18 x 109-441 x 109) compared with 31 x 109/L after 3 months of treatment (P = .303). Patients required a mean of 2.4 RBC units/month at the start of therapy vs 0.75 RBC units/month after 3 months of therapy (P = .099).

“The goal of this project was to [examine] the patients who have been treated so far at Moffitt Cancer Center with either pacritinib and/or momelotinib to gain a better understanding of the hematologic responses of these therapies, the duration of treatment, and other real-world data regarding these agents after they got their approvals,” Jeremy DiGennaro, MD, said during the presentation. “Patients receiving momelotinib and pacritinib are typically older with extended disease duration, multiple prior lines of therapy, high-risk mutations, and cytopenia. Pacritinib-treated patients have more prominent baseline thrombocytopenia. [However], there were favorable impacts on anemia and transfusion requirements [with both agents], although we still do need more long-term follow-up.”

DiGennaro is an internal medicine resident physician at the University of South Florida Morsani College of Medicine in Tampa.

In February 2022, the FDA granted accelerated approval to pacritinib for the treatment of adult patients with intermediate or high-risk primary or secondary myelofibrosis with a platelet count below 50,000/µL.2 Momelotinib was approved by the FDA in September 2023 for the treatment of adult patients with intermediate or high-risk myelofibrosis, including primary myelofibrosis or secondary myelofibrosis, and anemia.3

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Dr Klisovic on a Case Discussion of Momelotinib in Myelofibrosis With Anemia

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October 16, 2024

Author(s): Rebecca Klisovic, MD

Fact checked by: Ashling Wahner, Ryan Scott

Rebecca Klisovic, MD, chief medical information officer, University Hospitals Seidman Cancer Center, discusses 3 case studies about patients with myelofibrosis that were presented during an OncLive® State of the Science Summit™ on hematologic oncology, which she chaired.

The first case that was discussed was on a 71-year-old male patient with newly diagnosed myelofibrosis with splenomegaly, mild anemia, a high symptom burden, and intermediate-2–risk disease, Klisovic begins. The consensus among the panelists was that this patient required treatment due to his spleen size, symptoms, and anemia, she says. Although some oncologists who participated in the discussion considered using ruxolitinib (Jakafi) because of its early survival data, the panel predominantly favored momelotinib (Ojjaara), given this agent’s potential benefit in patients with anemia, she explains.

The second case was on a 62-year-old female patient with myelofibrosis who had already received ruxolitinib and had comorbidities including symptom scoring and a large spleen, according to Klisovic. This patient also had anemia, with a hemoglobin level of 7.2 g/dL, she reports. Therefore, the focus on improving anemia made momelotinib a clear treatment choice in this setting, she adds. Whereas other case presentations prompted treatment debates between the panelists, this case was more clear cut, especially since this patient was refractory to ruxolitinib, Klisovic emphasizes.

The third case was on a 54-year-old female patient with newly diagnosed myelofibrosis that was characterized by both anemia and thrombocytopenia, as well as a platelet count of 34/µL, Klisovic says. This discussion centered around the use of pacritinib vs momelotinib, informed by the patient’s low platelet count, she explains. Some discussants raised concerns about the patient’s eligibility for momelotinib clinical trials, which have enrollment criteria with varying platelet cutoffs, she notes. Despite these concerns, most participants favored the use of pacritinib (Vonjo) due to this agent’s efficacy in managing thrombocytopenia, she reports. However, some discussants noted that momelotinib could also be a viable treatment option for patients similar to the one in this case, depending on clinical trial criteria and individual patient factors, she concludes.

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Luspatercept Shows Promise in Alleviating Myelofibrosis-Associated Anemia

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Ryner Lai

Luspatercept shows promise in alleviating myelofibrosis-associated anemia and has a safety profile consistent with previous research, according to a study published in Blood Advances. 

The most common therapeutics in myelofibrosis include erythropoiesis-stimulating agents, androgens, corticosteroids, and lenalidomide. However, many of these are associated with significant adverse events (AEs). Researchers are investigating therapeutic agents that are highly effective against anemia while having an acceptable safety profile.

Luspatercept is an erythropoietin maturation agent that has been approved in the United States for treating anemia in some individuals with myelodysplastic syndromes or beta-thalassemia who need red blood cell (RBC) transfusion. This therapeutic has been shown to induce transfusion independence in approximately 38% of patients. Researchers sought to explore if the success of luspatercept can be replicated in myelofibrosis and conducted a study to assess its use in patients with myelofibrosis-associated anemia, with or without transfusion dependence.

Researchers reported results from a phase 2, multicenter, open-label trial that assessed the use of luspatercept in myelofibrosis. They recruited adult patients with myeloproliferative neoplasm (MPN)-associated myelofibrosis who possessed an Eastern Cooperative Oncology Group performance status score of 2 or less and had evidence of anemia. Patients were divided according to their transfusion dependence status and whether they were on ruxolitinib therapy.

Participants received subcutaneous luspatercept at a dose of 1.0 mg/kg (with titration up to 1.75 mg/kg every 21 days for a total of 24 weeks). They were then assessed for their disease response at day 169; if they demonstrated clinical benefits, they could continue receiving luspatercept treatment for approximately 2 years longer. The primary endpoint of this study was anemia response at the end of the 24-week period.

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Vonjo Improves Thrombocytopenia, Anemia in Patients With Myelofibrosis

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By Jax DiEugenio
Fact checked by Chris Ryan

Improvements in thrombocytopenia and anemia were observed in patients with myelofibrosis treated with Vonjo (pacritinib) in the real-world setting, as demonstrated in findings from a retrospective study presented at the 2024 SOHO Annual Meeting.

According to the National Cancer Institute, thrombocytopenia refers to a condition in which patients have a lower-than-normal number of platelets in the blood, and this can result in excessive bleeding from wounds and easy bruising. Anemia is a condition when patients have a low count of red blood cells.

Findings showed that patients with a platelet count below 100 x 109/L (which is considered low) at baseline (74 patients) experienced an early increase in platelet count following treatment initiation that was maintained throughout the observation period. Additionally, an early increase in median hemoglobin (a protein inside red blood cells that carries oxygen from lungs to tissues and organs) was reported in all patients, and this increase was sustained throughout the observation period. Patients with hemoglobin level of less than 8 g/dL (a level that indicates anemia) at the start of treatment (35 patients) experienced a hemoglobin increase of nearly 1 g/dL by day 30.

Notably, patients who received prior treatment with Jakafi (ruxolitinib; 69 patients) experienced an increase in platelet counts and hemoglobin levels following initiation of Vonjo. At baseline, the median platelet count and median hemoglobin level in this population was 91 x 109/L and 8.7 g/dL, respectively. At day 360, the median platelet count and median hemoglobin were 97 x 109/L and 10.4 g/dL, respectively.

“In addition to spleen and symptom benefits observed in previous clinical trials, real-world outcomes demonstrate stability or improvement in thrombocytopenia and/or anemia in patients with myelofibrosis treated with [Vonjo],” lead study author Michael Marrone and colleagues, wrote in a poster presentation of the data. Marrone is an assistant professor in the College of Medicine, Department of Public Health Sciences, at the Medical University of South Carolina in Charleston.

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Real-World Data for Pacritinib Show Improvement in Thrombocytopenia, Anemia in Myelofibrosis

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September 10, 2024

Author(s): Jax DiEugenio

Fact checked by: Chris Ryan

Pacritinib (Vonjo) generated improvements in thrombocytopenia and anemia in patients with myelofibrosis treated in the real-world setting, according to data from a retrospective study presented at the 2024 SOHO Annual Meeting.1

Findings showed that patients with a platelet count below 100 x 109/L at baseline (n = 74) experienced an early increase in platelet count following treatment initiation that was maintained throughout the observation period. Additionally, an early increase in median hemoglobin was reported in all patients, and this increase was sustained throughout the observation period. Patients with hemoglobin level of less than 8.0 g/dL at the start of treatment (n = 35) experienced a hemoglobin increase of nearly 1 g/dL by day 30.

Notably, patients who received prior treatment with ruxolitinib (Jakafi; n = 69) experienced an increase in platelet counts and hemoglobin levels following initiation of pacritinib. At baseline, the median platelet count and median hemoglobin level in this population was 91.0 x 109/L and 8.7 g/dL, respectively. At day 360, the median platelet count and median hemoglobin were 97.0 x 109/L and 10.4 g/dL, respectively.

“In addition to spleen and symptom benefits observed in previous clinical trials, real-world outcomes demonstrate stability or improvement in thrombocytopenia and/or anemia in patients with myelofibrosis treated with pacritinib,” lead study author Michael Marrone, PhD, MPH, and colleagues, wrote in a poster presentation of the data. Marrone is an assistant professor in the College of Medicine, Department of Public Health Sciences, at the Medical University of South Carolina in Charleston.

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Momelotinib Improves Anemia in JAK Inhibitor-Naive Myelofibrosis

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Sabrina Serani

Treatment with momelotinib (Ojjaara) delivered benefits to anemia among patients with myelofibrosis who were naive to JAK inhibitors, regardless of their baseline hemoglobin level. Further, momelotinib provided significant anemia benefits compared with ruxoltinib (Jakafi), according to an analysis from the phase 3 SIMPLIFY-1 study (NCT01969838).

SIMPLIFY-3 randomized 432 patients with myelofibrosis who had not received JAK inhibitors toreceive momelotinib or ruxolitinib.In patients who were anemic and received momelotinib, mean hemoglobin levels increased by weeks 2 to 4 of treatment, and hemoglobin levels remained stable among patients who were not anemic.

Comparatively, patients who were anemic and nonanemictreated with ruxolitinib experienced an initial decrease in mean hemoglobin. This decrease stabilized after weeks 4 to 6 as patients received red blood cell transfusions. Patients receiving ruxolitinib were permitted to cross over to the momelotinib group, and mean hemoglobin levels increased after this change.

The study also evaluated patients at different levels of anemia. Among patient who were mildly anemic, with ahemoglobin levelbetween 10 and 12 g/dL, 90.4% of patients were transfusion-free at baseline, 93.9% of these patients remained transfusion-free while receiving momelotinib. Four patients who were not transfusion-free at baseline became transfusion-free while on treatment. In contrast, patients who were mildly anemic in the ruxolitinib arm became more dependent on transfusion; 50% of patients who were transfusion-free at baseline required a transfusion while on ruxolitinib.

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Utilization of Momelotinib for Myelofibrosis With Anemia Can Result in Small Savings

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Laura Joszt, MA

Although momelotinib to treat myelofibrosis (MF) with anemia has a higher acquisition cost, it is partially offset by savings when transfusion-related costs are reduced, according to a poster being presented at the AMCP Annual Conference, held April 15-18, 2024, in New Orleans, Louisiana.1

MF is a rare cancer in the bone marrow that disrupts the production of blood cells.2 MF causes anemia because of the extensive scarring to bone marrow. This extensive scarring also causes patients to have a low number of platelets, increasing their risk of bleeding. Patients may also have an enlarged spleen.

Momelotinib inhibits Janus kinase (JAK) 1, JAK2, and activin A receptor type 1. In September 2023, the FDA approved momelotinib to treat patients with intermediate- or high-risk MF with anemia.3

The approval of momelotinib was based on data from the phase 3 MOMENTUM trial, which found clinically significant improvements for patients treated with momelotinib vs danazol.4 A quarter of patients treated with momelotinib had a 50% or greater reduction in total symptom score compared with only 16% of patients on danazol.

Since the approval, the National Comprehensive Cancer Network (NCCN) has added momelotinib5 to its Clinical Practice Guidelines in Oncology for Myeloproliferative Neoplasms. Momelotinib was added as a category 2A treatment for patients with high-risk MF. It was also added as a 2B category treatment for patients with lower-risk MF.

Patients with MF who have anemia and are dependent on transfusions have increased medical costs and poor prognosis, the authors of the AMCP poster noted. JAK inhibitors may provide improvements in symptoms and spleen size, but they could worsen or induce anemia. However, momelotinib has been shown to reduce spleen size.4

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