»The authors focus on improved blood count control, rates of thromboembolic events, symptom improvement, and markers of disease modification such as reduction of JAK2V617F allele burden in patients treated with ruxolitinib. They also discuss the well-characterized safety profile of ruxolitinib regarding hematologic and other adverse events of interest. In the 10 years since its approval, ruxolitinib remains a safe and effective standard-of-care treatment for PV. As the treatment landscape for PV continues to evolve in the coming years, the efficacy and safety profiles of ruxolitinib suggest it will remain a preferred treatment as monotherapy and as a potential backbone of future combination regimens. »
« Targeted treatments such as ruxolitinib have the potential to directly modify disease and therefore contribute toward long-term remission or a disease cure »
so pleased to read that and thanks for posting. I have been on rux for over 6 years and I call it my wonder drug - it changed my life overnight long may it continue working. Apart from whites platelets and Hb a bit on low side but I can live with that.
My consultant has mentioned about me starting Jakafi (Rux) in the near future. At the moment I am on Peginterferon 180 weekly which I am tolerating well. My platelets are steady at around 560-580, HCT 41-45. I have just had a venesection, my first one since january. At first I thought the change was being considered because of Peg shortage but consultant mentioned my levels, so not sure now, but will discuss with her at my next appointment. My issue is that she has told me that to qualify for Jakafi, I need to have tried and not tolerated Hydroxycarbamide which I do not want to do. I chose Peginterferon in the first place because I didn't want to go on Hydroxycarbamide 🙁 I was just wondering if anyone else has had this issue or whether they were just started on jakafi? Many thanks
I've discussed with my Dr. He's been involved with Rux since the start. He has PV pts on Rux for 10 years, he says they are doing well. I assume he has MF pts too, I'll try to ask next visit.
I asked about those pt's alellic burden, he said I'm the only pt that asks for it and thus has reported results. I guess his pts don't hang out here.
An aside, he just convinced one pt to get on Rux and quit the long term phlbs. He that that person feels a lot better now.
In one trial, (not the one plotted) after 8 years this was 68% to 3.5%.
Shingles: this risk consistently shows up, Hazard ratio is over 7. They and other reports recommend the vaccine, preferably before starting. For pts with prior Shingles consider antiviral valacyclovir.
Weight Gain They call this common adverse event at least a grade 3, while no unusual hazard is cited. So those upset about it can know these authors don't like it either.
Skin Cancer (MNSC) This report cites no clear added risk with Rux, while prior MNSC is a risk.
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Misc items:
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PV Risk factors: Newer models can also be considered, such as Mutation-Enhanced International Prognostic Scoring Systems-PV, which additionally integrates leukocyte count ≥15 × 109/L, age >67 years, and adverse SRSF2 mutations.
“…when criteria are modified ... 40% are resistant or intolerant (to HU).“ HU resistance in a negative prognostic as in this post, a large HR of 5-7 X higher risk of transformation or death. Most Rux studies have included mostly or only pts either intol or resist to HU. So the benefit from Rux for these pts in most Rux trials is notable.
“Targeted treatments such as ruxolitinib have the potential to directly modify disease and therefore contribute toward long-term remission or a disease cure.” The reference for this is directed more to IFN so they are inferring a same benefit with Rux; this report does cite those Rux benefits with respect to the plots here.
“JAK2V617F allele burden correlates with disease severity.” This is still not universally accepted, esp in a continuous proportional manner as implied here. The importance of achieving specific levels (ie 2, 10, 50%) has been a topic in posts. My MPN Dr is not yet convinced, but most members here seem to agree with some benefit.
Missed in that discussion were the small dots on the bars. These are non-drivers which are relatively scarce in the best responders. This is similar to IFN. Which non-drivers is not provided.
Fig. 1A is the first time seeing a Time vs VAF plot for Rux. Rux has a different effect than IFN, IFN starts steep and shallows, Rux is shallower to start and more constant long term. Mr Dr said this is typical for Rux, slow, steady. IFN in contrast has its best avg drop early. All Rux pts here were intol/resist to HU.
(12%) evaluable patients achieving JAK2V617F ≤2%. This appears in error or directed differently. The citation was an 8 year study and has: “JAK2 VAF reduced overall from a median of 68% …to 3.5%... “A profound and durable MR (DMR; defined as a VAF stably ≤2%), including complete MR in 8%, was achieved in 20% of the patients” Generally similar or possibly superior(the 3.5% median) to IFN in this regard, but it is one study.
Correlates to DMR: “A baseline JAK2 VAF <50%, and a VAF reduction of ≥35% after 2 years of treatment, predicted for the achievement of DMR and reduced progression to myelofibrosis.”
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“In both clinical trials and real-world studies, anemia was reported more frequently than thrombocytopenia and was more common in patients treated with ruxolitinib than BAT”. This might contrast with IFN where RBC counts can be slow to decrease as we see here. “Often, anemia and thrombocytopenia are low-grade and managed with dose reductions”
My PLT has been higher than it was on IFN.
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Safety:
Major adverse cardiovascular events
Exposure-adjusted incidence rates of MACE (acute myocardial infarction, stroke, or cardiovascular mortality) were similar between the ruxolitinib and control arms
Infections
“altered lymphocyte functioning” This likely is separate from low WBC counts, my Dr said this too.
For Shingles, hazard ratio (HR) is 7.39, so the risk is over 7X with Rux. Get the vaccine: “A nonlive subunit vaccine to prevent HZ may be considered for patients receiving ruxolitinib”. Best is before starting Rux according to reports that mention it. But there is no data I know of tracking efficacy of the vax in Rux pts. One report suggests both the antiviral valacyclovir and the vax for Rux pts with history of Shingles.
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They discuss other infections, which look to be not much increased with Rux in the numbers they provide. No HRs provided. More discussion here would be helpful, but looks good.
Nonmelanoma skin cancer (NMSC)
In one study that tracked it “incidence of NMSC was much higher in those who previously had NMSC than those who had not, regardless of treatment” “Furthermore, risk was not higher with ruxolitinib versus BAT in those with a history of NMSC”. This may be that HU has a similar risk for those with the history, if HU was the BAT.
Other nonhematologic adverse events
Dizziness in >10% of pts. This is new to me, any members having this? No others of singif in this category.
”Adverse events overall were less common with ruxolitinib treatment than with BAT”. BAT is mostly HU with a signif portion also being IFN as in prior posts.
Weight Gain
They call this a grade 3+ event“…approximately half of patients with MPNs gaining ≥5% their baseline body weight after initiating ruxolitinib.” So it’s also very common. They offer this encouragement: “in PV, a body mass index (BMI) under 25 kg/m2 (i.e., normal or underweight) may paradoxically be associated with lower overall survival compared with BMI ≥25 kg/m”
Postmarketing surveillance experience
“postmarketing safety data for ruxolitinib are generally consistent with data from randomized controlled trials”
“the most frequent AEs in the ruxolitinib postmarketing data overall were( low blood counts) and fatigue (2.5%)
“there is no evidence that ruxolitinib-treated patients with PV carry increased risk of MACE.”
“no emergence of new types or patterns of serious infections” vs trials.
“no conclusive evidence supports a causal relationship between ruxolitinib use and NMSCs.” (skin cancer) From the info above, prior MNSC is the primary risk factor.
“no difference in lymphoma incidence between patients with or without JAK inhibitor exposure”
Real world data “suggesting no association between ruxolitinib and … encephalopathies that are associated with some other JAK inhibitors”
Future directions: ruxolitinib in combination treatments for PV
“In COMBI-I, most patients were intolerant to IFN-α2 at baseline, but ruxolitinib addition enabled IFN-α2 administration at a lower, more tolerable effective dose.” This is discussed here:
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Treatment-free remission as a new goal for patients with PV
NICE Final Guidance on Ruxolitinib for the treatment of Polycythaemia Vera
