From the Guidelines
Imatinib is the tyrosine kinase inhibitor (TKI) for chronic myeloid leukemia (CML) that causes the least amount of swelling, with very few cases of pleural effusion reported, usually associated with pericardial effusions or advanced phases and doses above 400 mg daily. When treating CML, imatinib (Gleevec) has a lower risk of pleural effusion compared to other TKIs like dasatinib (Sprycel) and nilotinib (Tasigna) 1. According to the European LeukemiaNet recommendations, the incidence of pleural effusion with imatinib is very low, especially when used as first-line treatment 1. In contrast, dasatinib has a much higher risk of pleural effusion, with an incidence of 28% at 5 years of follow-up in the DASISION trial, compared to 1% with imatinib 1. Imatinib is generally well tolerated, with frequently reported adverse events including gastrointestinal disturbances, edema, rash, and musculoskeletal complaints, but these are usually manageable and do not lead to discontinuation of treatment 1.
Some key points to consider when using imatinib include:
- Starting dose: usually 400 mg once daily with food
- Monitoring: regular monitoring of complete blood counts, liver function, and renal function
- Management of toxicities: erythropoietin and filgrastim may be effective in managing imatinib-induced anemia and neutropenia, respectively 1
- Cardiotoxicity: long-term imatinib treatment may be associated with congestive heart failure and cardiotoxicity, although this is rare 1.
Overall, imatinib is a suitable option for patients with CML who are at risk of swelling or fluid retention, due to its lower risk of pleural effusion and manageable side effect profile.
From the Research
Tyrosine Kinase Inhibitors (TKIs) for Chronic Myeloid Leukemia (CML)
- The following TKIs are approved for the treatment of CML: imatinib, dasatinib, bosutinib, nilotinib, asciminib, and ponatinib 2
- Each TKI has a unique pharmacological profile and response pattern, and the choice of TKI should be based on patient and disease characteristics, such as comorbidities, disease stage, and BCR::ABL1 mutational status 3
Swelling Associated with TKIs
- Dasatinib is associated with a higher rate of pleural effusion compared to imatinib and nilotinib 4, 5, 6
- Nilotinib is associated with a higher rate of dermatologic toxicity, headache, and biochemical abnormalities associated with hepatic and pancreatic toxicity compared to imatinib 6
- Bosutinib is associated with gastrointestinal disturbance 2
- Imatinib is associated with edema, gastrointestinal AEs, musculoskeletal AEs, and rash 6
TKI with the Least Amount of Swelling
- Based on the available evidence, nilotinib may be associated with less swelling compared to dasatinib and bosutinib, as it has a lower rate of pleural effusion and gastrointestinal disturbance 5, 6
- However, nilotinib is associated with other adverse effects, such as dermatologic toxicity and biochemical abnormalities 6
- Imatinib may also be a suitable option for patients who experience swelling with other TKIs, as it has a lower rate of pleural effusion and gastrointestinal disturbance compared to dasatinib and bosutinib 5, 6