I wonder what the best strategy would be to control the rising blast count in the first week of starting Blinatumomab in a patient with refractory ALL?
Suggest you contact the Amgen team to discuss
If the patient is not having cytokine release syndrome or neurologic events, consider increasing to the 28 ug dose level sooner.
I agree that dosing with the goal of a complete MRD response in patients with a CR is different than in patients with relapsed/refractory disease and carries fewer toxicity concerns.
The dose of 15 μg/m2 is lower than what was previously given to relapsed patients (28 μg/m2 after the first week) in the original studies. At this dose, central nervous system toxicity is very low and can be managed with steroids. In that sense, it is well tolerated. The problem is the infusion: Daily infusion for 4 weeks over a 6-week period is challenging and cumbersome. It is more likely to be used in an academic setting than clinical practice.
From our experience it is usually not necessary to increase the dose in ALL (opposed to the situation in lymphoma). If the patient does not respond there is usually a different problem like loss of CD19 on the blasts. Increasind dose in ALL only leads to increased toxicity.
Thank you Dr. Raff and Dr. Payandeh for your responses. I talked to a couple of colleagues who had experience with the drug, and they suggested to increased the dose which I did, and the blast count started dropping. However, the patient developed seizure and we had to hold the therapy.
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