DR ERBA: For iron chelation therapy, there is no randomized trial showing a survival benefit with iron chelation therapy. We now have oral agents. Some of them are getting better tolerated, some of the newer formulations than deferoxamine or deferasirox. In any case, though, no randomized trial showing a survival benefit.

So I usually give my patients the benefit of the doubt though. Those patients who have low-risk disease, low-grade disease, primarily just anemia and are transfusion dependent, those are patients who I will consider for chelation therapy. Patients with intermediate- and high-risk disease, whose survival is shorter, I typically don’t.

One of the debatable points that comes up though is a younger patient with higher-risk disease. Should you chelate them because they’re going to go onto a transplant and unloading iron might be beneficial?

If you have that kind of time, sure, I think that makes sense. But typically you don’t have time to give long courses of iron chelation therapy. So I don’t see it as a benefit. And it can complicate things, given the renal/hepatic toxicity.

So basically, transfusion-dependent, low-risk patients with MDS I will consider iron chelation therapy.

DR LOVE: Guillermo, anything you want to add to what Harry just said?

DR GARCIA-MANERO: No. I agree with the chelation totally with what he said. I very rarely collect my patients. And I was part or am part of this randomized trial called TELESTO that was changed in size because it was difficult to accrue. And I wish I’d changed my practice soon, because at some point this data is going to come out and hopefully it will show a benefit. And then I will move to chelating everybody.

But there are several aspects. First of all, as Harry said, no true data. Second, toxic. And third, actually talking about drug prices — we have not really discussed this — these are like really extremely expensive indications. So for an oral compound with no track record with some toxicity, I think these are very problematic.

I, particularly, don’t believe the European data that was published maybe a decade ago. In my practice, very rarely I see heart disease and liver cirrhosis. I see once in a while. And I discussed this with the sponsors of this type of intervention, multiple locations, that unfortunately, we made a major mistake here. This intervention was extrapolated from the sickle cell anemia and the thalassaemia thinking, okay, you remove iron. This is good for your heart and your liver. Actually, people with MDS die from infection complications and transformation to AML, and the PT actually is that, hypothetically, it is possible that iron chelation could ameliorate the rate of infections and actually could decrease the risk of transformation. But it has never been really tested. And I think this extrapolation, at least in a North American population, is not 100% right.

So I use, and for sure I don’t use a ferritin level of 1,000 to start chelation. So I do it. Actually, for instance, extreme cases of people with hemochromatosis and MDS who already are stable like ferritin on 5, 10, yes. So I’ll do something like this. Or if the patient has heart disease.

The issue of the transplant is very important. That data was very hot a few years ago. But, even with my transplant colleagues, this doesn’t have a lot of traction. I guess they are concerned in terms of toxicity, spread transplant, et cetera.

Important clinical issues in the management of MDS

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