For me the trickiest part about PV has been deciding optimum treatment plan.
The options are:
If low risk, venesections and aspirin.
Otherwise principle choice is Interferon/Peg or HU with Ruxo a possible alternative for some.
The dilemma arises because there is no consensus amongst the experts.
Dr Silver, a highly respected US Hem, believes that too many venesections per annum can increase risk of progression and the ensuring anemia can be harmful. The leading UK expert (imo) disagrees. It’s a nightmare for our Hems since hinges on our individual acceptance of risk:reward.
All the drug options carry their own health warnings. HU increases risk of skin cancer but is generally well tolerated, quick acting and easy to administer. The Interferons have greater side effects for some (flu symptoms, depression and autoimmune) but offer a possible chance of slowing progression for a subset of lucky users. The dilemma has been do you risk taking Interferon when maybe 25% can’t tolerate and drop out and say only 25% achieve molecular remission (ie reduced Allele Burden and possibly marrow fibrosity). The more cautious Hems say, even if you achieve molecular remission, what is the clinical benefit re prognosis?
We now have Pegasys which is better tolerated than Interferon and recent trials (over longer time frames) have improved upon the 25% molecular response.
Ropeginterferon, an improved and better tolerated version of Peginteferon, is now in trials and could be available next year. The really interesting part of this trial, versus HU, is how after one year they were level pegging but after 2 years Ropeg pulling away on a molecular level. We are now into year 3......
My impression is that this is a bit of a game changer in terms of sentiment towards Interferon amongst the more cautious experts. Watch this 5 min clip and see what I mean. Remember HU is current front line choice.