Lisa Nodzon, PhD, ARNP, AOCNP®
Moffitt Cancer Center
Presentation and Diagnosis
A 68-year-old male presents with incidental finding of leukocytosis with differential showing immature myeloid forms and 2% peripheral blasts. He reports a 3-month history of fatigue. His past medical history includes hypercholesterolemia, myocardial infarction followed by coronary artery bypass surgery, COPD, and hypertension. Current medications include rosuvastatin, aspirin, metoprolol, irbesartan, and a formoterol-glycopyrrolate inhaler. After a complete workup including bone marrow biopsy, he is diagnosed with chronic phase CML, intermediate Sokal score.
Based on age, comorbidities, and intermediate Sokal score, he is initiated on nilotinib 300 mg po BID. Bone marrow biopsy at 1 year confirms complete cytogenetic response (CCyR) and major molecular response (MMR). After 4 years, bone marrow biopsy confirms cytogenetic relapse with identification of BCR-ABLT315I. He is transitioned to oral ponatinib 45 mg QD with recapture of CCyR and MMR by 3 months.
Cardiovascular Toxicity Mitigation and Management
Due to his strong cardiovascular (CV) history, the patient’s advanced practitioner (AP) collaborates with cardio-oncology to ensure he receives baseline and 3-6 month assessment of blood pressure (BP), fasting glucose, fasting lipid panel, echocardiogram, electrocardiogram, and ankle-brachial index.
After 3 months of ponatinib therapy, the patient reports persistent headaches and BP readings (SBP >150 and DBP >90). The AP determines that based on his BP diary readings, the patient has uncontrolled hypertension secondary to ponatinib despite being on metoprolol and irbesartan. In accordance with dosing recommendations based on the PACE trial,1 and achievement of CCyR with MMR, the AP reduces the oral ponatinib dose to 15 mg QD. At a 1-month follow-up appointment, the patient is maintaining MMR with resolution of headaches and controlled BP readings.
1. Cortes JE, Kim DW, Pinilla-Ibarz J, et al. Ponatinib Efficacy and Safety in Philadelphia Chromosome-Positive Leukemia: Final 5-year Results of the Phase 2 PACE Trial. Blood. 2018;132:393-404. http://doi.org/10.1182/blood-2016-09-739086