Which TKI? An embarrassment of riches for chronic myeloid leukemia patients

South Australian Health and Medical Research Institute, SA Pathology, and University of Adelaide, Adelaide, Australia

With the approval in many countries of nilotinib and dasatinib for frontline therapy in chronic myeloid leukemia,
clinicians now have to make a difficult choice. Because none of the 3 available tyrosine kinase inhibitors (TKIs) have
shown a clear survival advantage, they all represent reasonable choices. However, in individual patients, the case may
be stronger for a particular TKI. In the younger patient, in whom the prospect of eventually achieving treatment-free
remission is likely to be of great importance, dasatinib or nilotinib may be preferred, although their advantage over
imatinib in this setting remains to be proven. In patients with a higher risk of transformation (which is currently based
on prognostic scoring), the more potent TKIs may be preferred because they appear to be more effective at reducing
the risk of transformation to BC. However, imatinib still represents an excellent choice for many chronic myeloid
leukemia patients. All of these considerations need to be made in the context of the patient’s comorbidities, which may
lead to one or more TKIs being ruled out of contention. Whatever first choice of TKI is made, treatment failure or
intolerance must be recognized early because a prompt switch to another TKI likely provides the best chance of
achieving optimal response.

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