Tag Archives: JAK inhibitor

Emerging Therapies in Myelofibrosis Could Extend Beyond JAK Inhibitors

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March 24, 2025

Author(s): Ashley Chan

Fact checked by: Ashling Wahner

The September 2023 FDA approval of momelotinib (Ojjaara) for the treatment of patients with primary and secondary myelofibrosis with anemia provided the treatment paradigm with its fourth FDA-approved JAK inhibitor, a class of drugs that has helped improve symptoms associated with myelofibrosis and decrease spleen size, according to Raajit Rampal, MD, PhD.

Additional classes of drugs, such as BET inhibitors and immunotherapy agents, are also currently under investigation in clinical trials and could become “game-changers” if effective, Rampal noted.

“The major [message is] that myelofibrosis is not a monolithic disease, and the selection of the treatment needs to be tailored to the underlying issues and challenges the patient is facing,” said Rampal in an interview with OncLive®.

In the interview, Rampal discussed currently available JAK inhibitors and their limitations, emerging treatments for myelofibrosis, tips for treatment selection, and his takeaways from the 6th Annual Miami Cancer Institute Global Summit on Immunotherapies for Hematologic Malignancies.

Rampal is a hematologist-oncologist, the director of the Center for Hematologic Malignancies, and the director of the Myeloproliferative Neoplasms Program at Memorial Sloan Kettering Cancer Center in New York, New York.

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Optimizing Myelofibrosis Care in the Age of JAK Inhibitors

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Author: Douglas Tremblay, MD

How do you assess a patient’s prognosis at the time that they are diagnosed with myelofibrosis?
In the clinic, we use several scoring systems that have been developed based on the outcomes of hundreds of patients with myeloproliferative neoplasms (MPNs) to try to predict survival from time of diagnosis. Disease features associated with a poor prognosis include anemia, elevated white blood cell count, advanced age, constitutional symptoms, and increased peripheral blasts. Some of these scoring systems also incorporate chromosomal abnormalities as well as gene mutations to further refine prognostication.1

Determining prognosis can be important to creating a treatment plan, particularly to decide if curative allogeneic stem cell transplantation is necessary. However, I always caution patients that these prognostic scoring systems cannot tell the future and that each patient may respond differently to treatment.

How do you monitor for disease progression?
I will discuss with patients how they are feeling in order to determine if there are any new or developing symptoms that could be a sign that their disease is progressing. I will also review their laboratory work looking for changes in blood counts that could be a signal of disease evolution.

For instance, development of anemia or thrombocytopenia may signal worsening bone marrow function or progression to secondary acute leukemia. If there are concerning signs or symptoms, I will then perform a bone marrow biopsy with aspirate that will include assessment of mutations and chromosomal abnormalities to determine if their disease is progressing.

What are the first-line treatment options for a patient newly diagnosed with myelofibrosis, and how do you determine the best course of action?
For patients with myelofibrosis, the first-line treatment options include Janus kinase (JAK) inhibitors, which are effective at improving spleen size and reducing symptom burden. The US Food and Drug Administration (FDA) has approved 4 JAK inhibitors for the treatment of myelofibrosis: ruxolitinib, fedratinib, pacritinib, and momelotinib (Table).2-13 In general, ruxolitinib is the first-line treatment option unless there is thrombocytopenia, in which case pacritinib is more appropriate. In patients with baseline anemia, momelotinib may be the best choice.

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JAK Inhibitors Reduce Thromboembolic Risk in Myeloproliferative Neoplasm Therapy

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March 11, 2025

Author(s): Alex Biese

Fact checked by: Ryan Scott

Treatment with Janus kinase inhibitors (JAKis) has been found to be associated with a reduction in risk of thromboembolic events among patients with myeloproliferative neoplasms (MPNs), according to research findings.

These findings were published in eJHaem, and are driven by observations of treatment with Jakafi (ruxolitinib) for patients with polycythemia vera and myelofibrosis, researchers noted.

“In this meta-analysis, JAKi [used for] MPN [treatment] was associated with a reduced risk of thromboembolic events compared [with] control, primarily driven by studies of [Jakafi] in polycythemia vera and myelofibrosis,” first study author Roberta Dunn and colleagues wrote in the study. “JAKi treatment was not associated with an increased risk of [major adverse cardiovascular events] or hypertension, adding to the existing body of evidence demonstrating the safety of JAKi in the treatment of MPNs. Further prospective clinical trials are warranted to confirm these findings and characterize the cardiovascular profile of other JAKis in all types of MPNs.”

Dunn is a medical student at the School of Medical Education, King’s College London, as well as a student researcher at Guy’s and St Thomas’ NHS Foundation Trust, in the United Kingdom.

MPNs, according to the Cleveland Clinic, are rare blood cancers that involve the patient’s body making too many red blood cells, white blood cells or platelets. JAKis, as explained by the National Cancer Institute, block the actions of enzymes which control cell signaling and growth, the number of blood cells and platelets made in the bone marrow, inflammation, and immune cell activity. Blocking these enzymes may help prevent abnormal blood cells or cancer cells from growing.

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Optimizing Myelofibrosis Care in the Age of JAK Inhibitors

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December 12, 2024|Hematology and Oncology
Douglas Tremblay, MD

Myelofibrosis is a rare but serious bone marrow disorder that disrupts blood cell production and often leads to debilitating symptoms. In this interview, Douglas Tremblay, MD, Assistant Professor at the Tisch Cancer Institute, discusses the process for selecting the best treatment pathway for patients – from evaluating disease prognosis to navigating treatment resistance and intolerance.

Dr. Douglas Tremblay

How do you assess a patient’s prognosis at the time that they are diagnosed with myelofibrosis?
In the clinic, we use several scoring systems that have been developed based on the outcomes of hundreds of patients with myeloproliferative neoplasms (MPNs) to try to predict survival from time of diagnosis. Disease features associated with a poor prognosis include anemia, elevated white blood cell count, advanced age, constitutional symptoms, and increased peripheral blasts. Some of these scoring systems also incorporate chromosomal abnormalities as well as gene mutations to further refine prognostication.1

Determining prognosis can be important to creating a treatment plan, particularly to decide if curative allogeneic stem cell transplantation is necessary. However, I always caution patients that these prognostic scoring systems cannot tell the future and that each patient may respond differently to treatment.

How do you monitor for disease progression?
I will discuss with patients how they are feeling in order to determine if there are any new or developing symptoms that could be a sign that their disease is progressing. I will also review their laboratory work looking for changes in blood counts that could be a signal of disease evolution.

For instance, development of anemia or thrombocytopenia may signal worsening bone marrow function or progression to secondary acute leukemia. If there are concerning signs or symptoms, I will then perform a bone marrow biopsy with aspirate that will include assessment of mutations and chromosomal abnormalities to determine if their disease is progressing.

What are the first-line treatment options for a patient newly diagnosed with myelofibrosis, and how do you determine the best course of action?
For patients with myelofibrosis, the first-line treatment options include Janus kinase (JAK) inhibitors, which are effective at improving spleen size and reducing symptom burden. The US Food and Drug Administration (FDA) has approved 4 JAK inhibitors for the treatment of myelofibrosis: ruxolitinib, fedratinib, pacritinib, and momelotinib (Table).2-13 In general, ruxolitinib is the first-line treatment option unless there is thrombocytopenia, in which case pacritinib is more appropriate. In patients with baseline anemia, momelotinib may be the best choice.

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Dr DeAngelo on the Integration of JAK Inhibitors in Myelofibrosis Management

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November 11, 2024

Author(s): Daniel J. DeAngelo, MD, PhD

Daniel DeAngelo, MD, PhD, professor, medicine, Harvard Medical School, chief, Division of Leukemia, institute physician, Dana-Farber Cancer Institute, discusses the integration of JAK inhibitors into clinical practice for patients with myelofibrosis. Lower third needs to be updated

When incorporating JAK inhibitors, such as ruxolitinib (Rituxan), into clinical practice, it is essential to understand both their benefits and the challenges they present, particularly regarding anemia, DeAngelo begins. The phase 3 COMFORT-I (NCT00952289) and COMFORT-II (NCT00934544) trials, which initially sought to address symptom control and spleen reduction, demonstrated a notable survival advantage with ruxolitinib over placebo in patients with intermediate-2 or high-risk myelofibrosis, or intermediate-1 disease with symptomatic splenomegaly, he reports. These results led to ruxolitinib becoming the standard of care for high-risk or symptomatic patients, especially as allogeneic transplantation remains limited to select candidates, DeAngelo shares.

A primary consideration with ruxolitinib is its tendency to induce a hemoglobin level drop of approximately 2 points during the first 2 months of treatment due to on-target JAK2 inhibition, which affects erythropoiesis, he continues. Although newer agents are now approved by the FDA specifically for patients with baseline anemia, clinicians using ruxolitinib should anticipate this hemoglobin level decline, he states. Importantly, the initial drop in hemoglobin level does not indicate treatment failure but is a manageable effect that is often misunderstood, leading some oncologists to discontinue or reduce dosing with the drug prematurely, DeAngelo notes.

He goes on to state that his advice for integrating JAK inhibitors into myelofibrosis management plans is to proactively address these expected effects with patients. Patients can be supported through transfusions, growth factors, or alternative JAK inhibitors if needed, according to DeAngelo. In most cases, hemoglobin levels tend to stabilize and improve after the first few months, typically between months 3 and 4, he notes. Setting clear treatment expectations helps ensure patient adherence to therapy and optimizes outcomes when using JAK inhibitors in clinical practice, DeAngelo concludes.

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Dr Scandura on the SENTRY-2 Trial of Single-Agent Selinexor in JAK Inhibitor–Naive Myelofibrosis

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October 16, 2024

Author(s): Joe Scandura, MD, PhD

Fact checked by: Ryan Scott, Courtney Flaherty

Joseph M. Scandura, MD, PhD, associate attending physician, NewYork-Presbyterian Hospital; associate professor, medicine, Weill Cornell Medical College, Cornell University, discusses the phase 2 SENTRY-2 study (XPORT-MF-044; NCT05980806) evaluating single-agent selinexor (Xpovio) in JAK inhibitor–naive myelofibrosis.

The FDA granted fast track designation to single-agent selinexor for the treatment of patients with primary myelofibrosis, post-essential thrombocythemia myelofibrosis, and post-polycythemia vera myelofibrosis in July 2023. Notably, selinexor will be assessed in combination with ruxolitinib (Jakafi) in the phase 3 portion of the SENTRY trial (NCT04562389) and as a monotherapy in the phase 2 SENTRY-2 study for JAK inhibitor–naive patients.

The primary aim of the SENTRY-2 study is to evaluate the efficacy of selinexor as a standalone treatment for patients with myelofibrosis who have not previously been treated with a JAK inhibitor, Scandura begins. Currently, JAK inhibitors are the only FDA-approved class of drugs for this condition, complicating the ability to test alternative treatments like selinexor independently, he states. However, evidence suggests that selinexor demonstrates activity, prompting the FDA to permit the study’s initiation, Scandura says. In SENTRY-2, patients will start treatment with selinexor, and responses will be measured based on spleen volume reduction and symptom improvement, particularly anemia, he details.

An innovative aspect of the study is its flexibility, Scandura notes. If a patient shows some degree of response but it is not deemed significant, they may have a JAK inhibitor added to their treatment regimen, he explains. This could include ruxolitinib or newer agents such as pacritinib (Vonjoy), which does not suppress platelet counts, making it suitable for patients with low platelets. Momelotinib (Ojjaara), known for its efficacy in improving anemia, will be added if patients are anemic and maintain adequate platelet counts.

The importance of safety and rigorous science is emphasized in clinical trials, especially when evaluating new treatments, Scandura continues. With selinexor already recognized as safe, the focus shifts to optimizing its use in the treatment landscape of myelofibrosis, he says. If selinexor gains FDA approval for myelofibrosis, it could play a significant role in a more nuanced treatment approach, reflecting the complexities of managing this condition amidst financial considerations and the availability of multiple JAK inhibitors, Scandura concludes.

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JAK Inhibitors Diversify the Field of Myelofibrosis Symptom and Spleen Management

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October 8, 2024

Author(s): Ashling Wahner

Fact checked by: Courtney Flaherty

The wealth of JAK inhibitors available for managing myelofibrosis invites the development of increasingly personalized treatment plans based on individual patient needs and disease characteristics, according to Idoroenyi Amanam, MD.

“We’ve come a long way since ruxolitinib [Jakafi] was FDA approved,” Amanam said in an interview with OncLive®. “We have a better understanding of which patients benefit from JAK inhibitors, and we are clearer on the shortcomings of JAK inhibitors.”

In the interview, Amanam discussed how JAK inhibitors measure up against other available therapies in myelofibrosis; patient characteristics that are most likely to indicate benefit with JAK inhibitors; and which of these agents he is likely to choose based on patients’ platelet counts, symptom burden, and treatment history.

For instance, Amanam highlighted the importance of pacritinib (Vonjo) in the myelofibrosis treatment paradigm. Pacritinib was approved by the FDA in 2022 for the treatment of select adult patients with intermediate- or high-risk myelofibrosis with thrombocytopenia based on findings from the phase 3 PERSIST-2 trial (NCT02055781), in which 29% patients who received the agent achieved a spleen volume reduction (SVR) of at least 35%. Among patients who received best available therapy, the SVR rate was 3%.1

He also explained the role of momelotinib (Ojjaara) for patients with anemia. Momelotinib was FDA-approved in 2023 for the treatment of adult patients with intermediate- or high-risk myelofibrosis and anemia based on data from the phase 3 MOMENTUM trial (NCT04173494).2 In MOMENTUM, 25% of patients who received momelotinib (n = 32/130) experienced a Myelofibrosis Symptom Assessment Form 4.0 total symptom score reduction of at least 50% vs 9% of those who received danazol (Danocrine; n = 6/65), translating to a treatment difference of 16% (95% CI, 6%-26%; P < .0095).3

Amanam is an assistant professor in the Division of Leukemia in the Department of Hematology & Hematopoietic Cell Transplantation at City of Hope in Duarte, California.

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Janus kinase inhibitor monotherapy and combination therapies for myelofibrosis: what’s the current standard of care?

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Mahesh Swaminathana, Akhil Jain, Sungchul Daniel Choi & Naveen Pemmaraju
Received 10 Jun 2024, Accepted 23 Sep 2024, Published online: 03 Oct 2024

ABSTRACT

Introduction

JAK inhibitors (JAKi) have changed the treatment paradigm of myelofibrosis (MF). Currently, 4 JAKis are approved in the US as monotherapy (mono) to treat patients with MF. JAKis are also being studied in combination (combo) with novel agents. Herein, we review some of the key studies that evaluated JAKi as mono and combo in MF.

Areas covered

We performed a Pubmed search for ‘JAK inhibitors’ and ‘myelofibrosis’ from 1/2010 to 12/2023. For mono, we included only the unique phase II/III studies of the approved JAKi. Selective studies that evaluated JAKi in combo with the novel agents were also included.

Expert opinion

JAKis aim to provide clinical benefit to patients via spleen size reduction and MPN symptom improvement. In order to potentially increase clinical benefit for patients with MF, several novel agents are being partnered with ruxolitinib (RUX) with the ongoing hypothesis to augment greater measures of MF disease modification. The novel agents are either ‘added-on’ to RUX or as a combo in JAKi naïve patients. Also, the mutant-targeting era of therapies is now beginning with novel CALR-mutated, novel JAK2 V617F mutation-specific and type II JAK2i in the initial stages of drug development, representing a new approach to treatment.

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Choosing the Right JAK Inhibitor for Effective Myelofibrosis Treatment

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By Jordyn Sava
Fact checked by Sabrina Serani

With 4 JAK inhibitors approved in the US and additional agents in development, it is an exciting time for the field of myeloproliferative neoplasms (MPNs). Now, experts face the challenge of determining which treatment is best for each patient.

Ruxolitinib (Jakafi), an established JAK inhibitor, was first approved by the FDA in 2011,1 showing clear survival benefits. This was followed by the FDA approvals of fedratinib (Inrebic) in 2019,2 pacritinib (Vonjo) in 2022,3 and momelotinib (Ojjaara) in 2023.4

“Each [JAK inhibitor has] their place depending on the patient’s blood counts and other clinical factors,” explained Prithviraj Bose, MD, in an interview with Targeted OncologyTM.

With multiple JAK inhibitors available to choose from, a tailored approach ensures that each patient’s specific disease characteristics and comorbidities are considered to maximize efficacy and minimize toxicity during treatment.

In the interview, Bose, professor in the Department of Leukemia at MD Anderson Cancer Center, discussed the multiple JAK inhibitors available for the treatment of patients with MPNs.

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Dr Amanam on Criteria for Selecting a JAK Inhibitor in Myelofibrosis

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September 23, 2024

Author(s): Idoroenyi Amanam, MD

Idoroenyi Amanam, MD, assistant professor, Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, discusses the criteria for selecting JAK inhibitors in the treatment of patients with myelofibrosis.

Ruxolitinib (Jakafi) was the first JAK inhibitor approved for the treatment of myelofibrosis by the FDA in 2011. Amanam notes that this approval was initially based on the agent’s demonstrated benefits in reducing splenomegaly and improving symptom burden, two critical factors that influence treatment outcomes in myelofibrosis. Since then, 3 additional JAK inhibitors have received FDA approval for the treatment of select patients with myelofibrosis: fedratinib (Inrebic) in 2019, pacritinib (Vonjo) in 2022, and momelotinib (Ojjaara) in 2023.

Amanam emphasizes that the ideal candidates for JAK inhibitors are patients experiencing significant symptom burden and splenomegaly. Patients presenting with myelofibrosis, particularly those with moderate to severe spleen enlargement and a high burden of disease-related symptoms, are likely to derive the most benefit from JAK inhibition, he continues.

Conversely, patients who are not experiencing splenomegaly or any symptom burden may have limited therapeutic gain from JAK inhibitors, and the use of these agents in these patients may expose them to unnecessary risks of adverse effects (AEs), he says. The most commonly reported AEs from JAK inhibitor treatment are cytopenias, such as anemia, thrombocytopenia, and leukopenia, Amanam notes.

To avoid these potential toxicities, Amanam stresses the importance of thorough patient evaluation and symptom assessment when considering JAK inhibitors, as the absence of these key criteria can reduce the overall efficacy of treatment and increase the potential for unnecessary AEs.

In clinical practice, Amanam explains the importance of personalized treatment strategies based on individual patient characteristics and risk profiles, prioritizing those who meet the established clinical benchmarks for symptom relief and splenic volume reduction.

Although JAK inhibitors can offer significant symptomatic relief for appropriately selected patients, they are not universally beneficial for all patients with myelofibrosis and should be used judiciously to optimize clinical outcomes, he concludes.

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