A 68-year-old woman with primary myelofibrosis presented with mild fatigue and an enlarged spleen palpable 6-7 cm below the left costal margin. Her diagnosis was confirmed by bone marrow biopsy showing megakaryocyte proliferation with reticulin fibrosis, and blood smear revealing leukoerythroblastosis. Genetic testing identified a JAK2 V617F mutation with a normal karyotype (46,XX).
The patient was classified as intermediate-risk by both the Dynamic International Prognostic Scoring System (intermediate-1/2) and the Mutation-Enhanced International Prognostic Scoring System for Transplantation-Age Patients. Laboratory values showed moderate anemia with hemoglobin of 9.7 g/dL, elevated white blood cells at 23.0 × 10^9/L, and normal platelets at 450 × 10^9/L.
Hemoglobin Levels Guide JAK Inhibitor Selection
Experts are increasingly tailoring treatment approaches based on hemoglobin levels in myelofibrosis patients. Dr. Nicole Jacobi noted that while ruxolitinib (Jakafi) remains a standard option for many patients, momelotinib (Ojjaara) is now preferred for those with more severe anemia.
"I chose momelotinib twice, but I was on the fence before," Dr. Jacobi explained. "I always think if I get the chance to get ruxolitinib in, as long as the platelets are still OK, I should use it. I would likely use ruxolitinib with the other scenario and momelotinib now."
Dr. Rupa Chennamaneni echoed this approach: "I picked ruxolitinib because of the familiarity and the survival benefit. In the scenario of severe anemia, I changed to momelotinib."
This shift in treatment strategy highlights the clinical significance of hemoglobin levels in therapeutic decision-making. When presented with a similar patient whose hemoglobin was 7.8 g/dL instead of 9.7 g/dL, most physicians indicated they would select momelotinib over ruxolitinib.
Managing Anemia in Myelofibrosis
Beyond JAK inhibitor selection, physicians discussed complementary approaches to address anemia in myelofibrosis patients.
Dr. Pallavi Jasti advocated for erythropoietin-stimulating agents (ESAs), particularly when serum erythropoietin levels are below 500 U/L. Dr. Chennamaneni mentioned using luspatercept (Reblozyl) as another option for anemia management.
Danazol, an anabolic steroid, was also discussed, though Dr. Mark Fesler noted limited success in his experience: "Several patients I've used it on remain transfusion dependent in spite of danazol therapy. It was tough to realize the exact benefit."
Timing of JAK Inhibitor Initiation
The panel discussed when to initiate JAK inhibitor therapy in intermediate-risk patients, particularly those who may be asymptomatic.
Dr. Karim Anwar suggested: "If the patient has minimal or no symptoms or intermediate grade, I might hold. I don't know if such a patient will qualify for intermediate grade, but if there are no cytopenias, I might just watch and initiate it once I see some symptoms or spleen enlargement."
Dr. Fesler clarified that intermediate risk encompasses both intermediate-1 and intermediate-2 categories, with symptoms typically increasing as risk profiles escalate. "At intermediate-1, we more often see patients who are asymptomatic. The struggle is, do you start JAK inhibitors for those patients, or do you wait?"
He acknowledged that both approaches have merit: "In a completely asymptomatic patient, careful monitoring of spleen and symptoms to see where the natural history of the disease is going is a legitimate way of handling this. But one could make an argument we should treat that patient right off the bat."
For intermediate-2 or higher-risk patients, most experts expressed less comfort with watchful waiting and favored active treatment.
JAK Inhibitors as Bridge to Transplant
For transplant-eligible patients like the 68-year-old woman in the case study, experts discussed how JAK inhibitor therapy might influence transplantation outcomes.
Dr. Melhem Jabbour raised an important question: "Does any drug between ruxolitinib, pacritinib, or momelotinib affect the transplant down the road? Is there anything we should not do before transplant, or is there a preferred bridging?"
Dr. Saurabh Chhabra, a transplant physician, clarified: "I don't think there are any data suggesting that we should use only one particular JAK inhibitor. Most of the experience that we have is with ruxolitinib, but we're seeing more and more experience with pacritinib now."
He emphasized the primary goals before transplantation: "At the end of the day, we want to control the symptoms, reduce the spleen size, and buy more time so that we have a donor available and have the comorbidities managed properly."
Dr. Fesler noted that reducing spleen size before transplantation may be particularly important, as "having a larger spleen going into transplant might be an adverse prognostic factor."
Dr. Jacobi cautioned about the timing of transplantation: "I tend to send out patients relatively early, when they're young, but I feel like the medication route needs to be walked down to the very end... The transplant is being done at a much later point."
Survival Benefits of JAK Inhibitors
When asked about survival benefits compared to traditional therapies like hydroxyurea, Dr. Fesler noted that ruxolitinib has demonstrated an overall survival advantage in the COMFORT-1 and COMFORT-2 studies. However, similar survival data for newer JAK inhibitors like momelotinib, pacritinib (Vonjo), and fedratinib remain to be established.
Quality of Life Considerations
The experts identified fatigue and early satiety due to splenomegaly as the symptoms most negatively impacting patients' quality of life. Dr. Jacobi noted, "Fatigue is a big issue, and the other one is early satiety, looking at the patient's spleen and consecutive weight loss from that."
These quality of life considerations, along with objective measures like spleen size and blood counts, guide treatment decisions for myelofibrosis patients across risk categories.
Practical Challenges in Treatment
The panel also addressed practical challenges in JAK inhibitor administration. One physician raised concerns about adherence issues with twice-daily dosing of ruxolitinib, asking whether once-daily dosing might provide similar benefits.
Dr. Fesler cautioned against this approach: "The pharmacokinetics of the drug would suggest that even if you're getting down to low dosages, 5 to 10 mg on a daily basis, the drug is designed to be given twice daily, so those patients may not be experiencing the full benefit."
He also warned about potential rebound cytokine release with inconsistent dosing: "If they take it at 9 AM, then by 9 PM or in the middle of the night, they might start to experience some adverse symptoms that could be somewhat related to ruxolitinib withdrawal."
