[ Inglés] ASH 2014 Coverage: Dealing with MPN-Related Anemia and Fatigue

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Topics include: Treatments and Understanding

One of the greatest unmet needs in myelofibrosis is the treatment of anemia. At the 2014 American Society of Hematology Meeting, Dr. Ruben Mesa joined Patient Power to discuss MPN-related anemia and fatigue and what can be done about it. He explained the cause of anemia, why it varies for different types of MPN patients, potential treatments and why it’s important to bring up any changes with your physician.

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Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:

Hello and welcome to Patient Power.  I’m Andrew Schorr, and we’re in San Francisco at the American Society of Hematology Meeting. And we’re talking about MPNs, and we’re back with our old friend Dr. Ruben Mesa, from the Mayo Clinic in Scottsdale, and we want to hear the latest.  Dr. Mesa, first of all, thanks for being with us, once again.

Dr. Mesa:               

Thank you, Andrew.  Always a pleasure.

Andrew Schorr:                 

Okay.  Now, there’s the concern for some patients with myelofibrosis, but other MPNs as well, about anemia. They’re just tired.  Fortunately, it hasn’t happened to me with myelofibrosis, yet.  I hope never, but it’s something we worry about so, where are we with that, now?  First of all, what is going on when you have anemia, and are options improving for that?

Dr. Mesa:               

Anemia, in myeloproliferative disorders is really quite complex, and there are many things that contribute to it.  First of all, we mean by anemia is that the number of red blood cells in the bloodstream are less than they should be, which typically, is about a level of less than 13-1/2 for men and less than 12 for women.  Now, what we consider significant anemia, many patients will have mild anemia.  Let’s say a value between 10 to 13 and a half, or 10 to 12.  We consider it’s more significant is when patients are eight to 10 or if below a level of eight, many patients may require a transfusion.  Surely, somewhere between seven and eight, most patients would get transfusions.

As we become more anemic, our body feels a lack of energy.  In part, because the whole purpose of the blood is to carry oxygen from our lungs to the rest of the body so if we have less blood, we truly have less ability for our tissues to get that oxygen. So if we’re active, whether that’s walking up a flight of stairs, whether that’s walking across our house, we can feel more winded so, that’s why anemia really can matter.  Now, why we develop anemia with an MPN can be for many reasons.  First, particularly, in myelofibrosis, the bone marrow is producing less red blood cells.  Literally, the bone marrow’s a factory for making the blood, and it’s making less cells. 

Now, part of that can be because of the disease.  Part, can because we don’t have enough building blocks, so individuals can be iron deficient.  If they’re iron deficient, that can also add to anemia.  People can have, sometimes, the spleen act a bit as the tax man on the bloodstream.  The spleen is much larger than normal.  It’s a filter for the blood.  It can hold on to almost up to one to two units of blood.  Patients can even have less common causes for anemia, such as bleeding that is hidden or internal bleeding, or even destruction of red cells early.

Then, finally, some of the medicines that we take for myelofibrosis, such as JAK inhibitors, or hydroxycarbamide (Hydrea), or interferon, all, they themselves can cause some degree of anemia. So, as you see, there [are] many different contributors, in part as—you know patient and I visit is trying to figure out, one, do they have anemia?  Two, is the anemia a problem?  And three, what is the cause for the anemia?  Is there something that is reversible?  Let’s say they’re iron deficient.  We can give them iron, or B12, or is it really from the disease?  Now, from disease related anemia in myelofibrosis, that always has been a difficult challenge, but there have been several things that have helped.

One, erythropoietin sometimes helps.  Erythropoietin is a hormone from the kidneys. And if our body’s not making enough of that hormone that stimulates red cell production, patients can get injections of that.  Medicines such as epoetin alfa (Procrit) and others, to try to improve the anemia.  Two, sometimes the male hormone, testosterone, can help.  As we age, you and I, unfortunately, we have less testosterone as we age.  Even women have testosterone, although, at lower levels.  We all lose testosterone, as we age so, sometimes replacing testosterone can help raise our red blood cell levels.

Finally, we’ve investigated many drugs to try to see if they can help to improve anemia.  There are some that have helped from the past, in part. Lenalidomide (Revlimid®), thalidomide (Thalomid®), in particular, have helped, to some degree.  Anemia is still thought to be one of the great unmet needs in myelofibrosis, in terms of treatments.  As we learn at this meeting about many different clinic trials, whether agents alone, such as imetelstat or in combination with JAK inhibitors, such as ruxolitinib (Jakafi®) and anti-fibrosing drugs, like PRM151, or smoothened inhibitors, or PI3 kinase inhibitors.   In part, they’re judged by seeing can they help to improve anemia.

Andrew Schorr:                  

Okay.  Now, along the JAK inhibitors, would it—one be better than another, related to anemia, or do we know, yet, because many people are going on JAK inhibitors?

Dr. Mesa:               

There does seem to be some difference between the JAK inhibitors, in terms of anemia, and as I share with folks, there [are] really two types of anemia in that setting.  One, is there less anemia, in terms of the drug causing anemia, which they can do, or two, can they help to improve the anemia that you started with, because the mechanisms for each might be slightly different?  There [are] three main JAK2 inhibitors.  There’s ruxolitinib, which is approved, and it can cause some anemia.  It typically is more common early on in the course of treatment, with some recovery of the red cells, but we typically don’t see the red blood cell count improve over baseline in people with ruxolitinib. 

Two is momelotinib, developed just really a few miles from here in Foster, California.  That agent, in early trials, suggested that there might be some benefit for anemia, and it’s currently in a Phase III trial in the U.S., and in Europe, of ruxolitinib versus that agent, momelotinib, to see is there truly a difference or superiority for anemia.

The third drug is pacritinib, that in the early studies that I was involved with seem to, one, not lower the platelet counts so, potentially, be used in patients with lower counts, but two, potentially help anemia. So there is some subtle differences between the three of them, and we really look for the large studies to be completed so that we can have more accurate comparison between them.

Andrew Schorr:                  

Okay.  One question; we’re talking about sometimes feeling bone tired.  You mentioned the effects of anemia.  When do you, as a doctor, want the patient to speak up?  Not just at the visit, but between visits, with these sorts of things that they’re feeling.

Dr. Mesa:               

Well, what I notice about patients with MPNs, having seen so many over the years, is that they’re diseases that people tend to be relatively stable with, in terms of how they’re feeling so, whether they’re feeling well, whether they’re feeling poorly, it does tend to be fairly consistent, and that patients, themselves, typically can tell is something feeling different?  Am I feeling much more tired than I really normally do?  Am I feeling incredibly winded, where I normally wouldn’t be?  Am I having fevers, and this is an unexpected change?  Am I seeing unexpected bleeding or anything of concern? 

These are diseases that unexpected things can occur. So I can say that if people really think that, boy, something feels different, it usually is wise to let their doctors know, and then, we take a look at it.  Is there a change we see in the blood tests?  Is it related to the disease?  Is it related to something else? But it’s best to feel free to really speak up, if something feels different, so that we can catch it earlier, rather than later.

Andrew Schorr:                  

Dr. Ruben Mesa, thank you for helping us understand about a major thing for a lot of people is when they’re so tired, and it could be this anemia, also, helping us understand sort of when to call the doctor, when to speak up.  It’s very helpful.  Thanks for being with us again.

Dr. Mesa:               

Always a pleasure.  Thank you.

Andrew Schorr:                   

Okay.  Andrew Schorr at the American Society of Hematology Meeting with our friend, Dr. Mesa, and bringing you, always, the latest information and perspective for MPNs.  Remember, knowledge can be the best medicine of all. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on October 26, 2015