Dr Kishtagari on JAK Inhibitor Selection for Myelofibrosis in the Community Setting

Ashwin Kishtagari, MD, clinical research fellow, Bick Lab, assistant professor of medicine, Hematology and Oncology, Vanderbilt School of Medicine, offers insights on the management of myelofibrosis in the community health care setting, specifically regarding the selection of JAK inhibitors for this patient population and how cytopenias could affect treatment decision-making.

Currently, there are 4 JAK inhibitors approved by the FDA for the treatment of myelofibrosis: ruxolitinib (Jakafi), fedratinib (Inrebic), pacritinib (Vonjo), and momelotinib (Ojjaara). Community oncologists may be more familiar with ruxolitinib since it was first approved in 2011, Kishtagari says. However, the other 3 agents have all entered the treatment armamentarium since 2019, and Kishtagari underscores the importance of considering their use JAK inhibitors in specific clinical scenarios where they are indicated. For instance, pacritinib, which received accelerated approval in 2022, is indicated for patients with intermediate- or high-risk primary or secondary myelofibrosis with a platelet count below 50 x 109, and it can be used safely without exacerbating the low platelet count, Kishtagari explains.

Moreover, for patients presenting with anemia as a predominant symptom, Kishtagari recommends the use of momelotinib, which has demonstrated efficacy in improving hemoglobin levels. In 2023, the FDA approved momelotinib for use in adult patients with intermediate or high-risk myelofibrosis, including primary myelofibrosis or secondary myelofibrosis, and anemia. Momelotinib can cater to the specific needs of patients and optimize therapeutic outcomes by addressing the issue of anemia, he says.

When a patient presents with myelofibrosis, identifying any underlying cytopenias is paramount to drive JAK inhibitor treatment selection, Kishtagari continues. In patients with preserved blood counts, ruxolitinib remains the preferred option, he notes; however, in the presence of thrombocytopenia, he advocates for the use of pacritinib, and in cases of anemia, momelotinib is recommended.

Understanding the role of underlying cytopenias on JAK inhibitor selection in myelofibrosis is key for oncologists practicing in community settings, he says. Tailoring therapy based on individual patient characteristics allows for more personalized care and potentially improves patient outcomes by directly addressing the specific pathophysiological challenges posed by different forms of cytopenia in myelofibrosis, Kishtagari concludes.