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Blood, 1 November 2002, Vol. 100, No. 9, pp. 3434-3434
CORRESPONDENCE
To the editor:
Managing cutaneous reactions to imatinib therapy
Cutaneous reactions to imatinib therapy are increasingly being
recognized, with up to 21% of patients experiencing mild to moderate
reactions at doses of 600 mg and higher.1 A recent case
report of Stevens-Johnson syndrome complicating the use of imatinib2 expressed caution in the widespread use of this
agent based on such reactions. We wish to illustrate that significant mucocutaneous eruptions can be managed, enabling long-term continuation of imatinib therapy. Case 1 involved a 66-year-old woman with chronic-phase chronic
myeloid leukemia (CML) who was intolerant of therapy with
interferon- and was started on imatinib at a dose
of 400 mg daily. After 10 days of therapy, she developed a macular,
pruritic rash together with mild periorbital edema. The following day,
this had progressed into a disseminated rash with confluent areas over
the torso and upper limbs. In addition, there were oral and vaginal
mucosal erosions. The skin was not biopsied, but a clinical diagnosis of Stevens-Johnson syndrome was made and imatinib was discontinued. No
other medication could be implicated. In the next 2 weeks, the rash
slowly resolved without the use of steroids. The patient was very keen
to restart the medication, and after 3 weeks the drug was started at a
lower dose of 300 mg daily. The following day, she developed a pruritic
erythematous eruption on her arms that suggested early recurrence. The
drug was stopped again and oral prednisolone started at a dose of 30 mg
daily. The rash quickly resolved. Two days later the imatinib was
restarted at 300 mg together with the prednisolone. There was no
further recurrence of the rash. In the next 5 weeks the prednisolone
was slowly reduced and stopped while the dose of imatinib remained
constant at 300 mg. The patient has been on the drug for a further 15 months with no further recurrence of the rash and is in complete
cytogenetic remission. Case 2 involved a 33-year-old woman with chronic-phase CML who was
started on imatinib, 400 mg daily, because of interferon- intolerance. After 2 weeks she developed an extensive pruritic maculopapular rash. She was advised to stop the imatinib and within a
few days the rash had completely cleared. She did not require any
steroids. No other cause for the rash could be found and she was not on
any other medication. One week after the rash had cleared she was
restarted on 100 mg imatinib daily. A week later the dose was
increased to 200 mg with no recurrence of the rash and after 4 weeks
the dose was again increased, to 300 mg. This was well tolerated, and
after 6 weeks the dose was increased to 400 mg daily. By gradually
increasing the dose of imatinib we were able to achieve the standard
dose without recurrence of the rash. This patient has now been on
treatment for 7 months and is currently 99% Philadelphia negative. Imatinib is the most active agent for the treatment of CML, and skin
rashes are quite common with this agent.1,3
Although caution must be exercised when skin rashes occur,
these cases, and others that we have observed, illustrate that it is
possible to continue imatinib treatment by using concommitant
short-term steroid therapy or by reintroducing imatinib with gradual
dose escalation. Although we do not advocate the ongoing use of
imatinib in patients who develop very severe skin reactions, careful
management and perseverance can often allow patients who develop mild
to moderate skin rashes to continue with the drug.
Simon A. J. Rule, Stephen G. O'Brien, and Lucy C. Crossman
Correspondence: Simon A. J. Rule, Department of Haematology,
Derriford Hospital, Plymouth, PL6 8DH United Kingdom;
e-mail:
simon.rule{at}phnt.swest.nhs.uk
References
1.
Brouard M, Saurat JH.
Cutaneous reactions to STI571.
N Engl J Med.
2001;345:618-619[Free Full Text].
2.
Hsiao LT, Chung HM, Lin JT, et al.
Stevens-Johnson syndrome after treatment with STI571: a case report.
Br J Haematol.
2002;117:620-622[CrossRef][Medline]
[Order article via Infotrieve].
3.
Brouard MC, Prins C, Mach-Pascual S, Saurat JH.
Acute generalized exanthematous pustulosis associated with STI571 in a patient with chronic myeloid leukemia.
Dermatology.
2001;203:57-59[CrossRef][Medline]
[Order article via Infotrieve].
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