BCR-ABL tyrosine kinase inhibitors in chronic myeloid leukemia: using guidelines to make rational treatment choices

The success of the BCR-ABL tyrosine kinase inhibitor (TKI) imatinib in improving prognosis in chronic myeloid leukemia (CML) has led to its wide use as first-line therapy at a standard dose of 400 mg daily. As more patients have undergone therapy, the development of molecular and clinical resistance to imatinib has raised further therapeutic challenges. The 2 main approaches to overcoming resistance are imatinib dose escalation and the use of alternative more potent TKIs, such as dasatinib or nilotinib. The phase II SRC/ABL Tyrosine Kinase Inhibition Activity Research Trials (START) of dasatinib have established dasatinib as potent and effective in overcoming imatinib resistance or intolerance in all phases of CML. The most recent treatment guidelines by the National Comprehensive Cancer Network now contain recommendations for using dasatinib in this setting. The issue of when to change from imatinib to an alternative agent in preference to imatinib dose escalation is keenly debated, particularly as new clinical evidence emerges, which highlights the importance of achieving early cytogenetic and molecular responses for a good long-term outcome. Identifying patients in whom a change to dasatinib or nilotinib is more appropriate than imatinib dose escalation is therefore important.