Therapeutic Drug Monitoring of Imatinib in Patients of Chronic Myeloid Leukemia - Chronic Phase

Introduction: Tyrosine kinase inhibitor is recommended for the initial management of chronic phase chronic myeloid leukemia (CP CML) based on the more favorable balance of toxicity and long-term disease control. Background: Mean trough plasma Imatinib Mesylate (IM) levels are detected to be significantly higher in patients with a complete cytogenetic response or major molecular response (MMR). Methodology: The primary objective of the study was to correlate the IM drug levels with MMR on two different occasions at least 3 months apart and to study the variation in the plasma trough levels of IM during the treatment with standard dose for at least 12 months. Results: After exclusion, 30 patients of CML-CP in MMR, on standard dose over a period of 2 years were finally analyzed. The mean IM plasma levels (IPLs) of the first sample for all patients were 1722 ± 566 ng/ml (IPL-1) with a corresponding mean molecular response (MR) 0.0257 ± 0.0279 breakpoint cluster region-abelson murine leukemia (BCR-ABL) IS % (MR-1). The mean IPLs of the second sample for all patients were 1549 ± 375 ng/ml (IPL-2) with a corresponding mean MR 0.0143 ± 0.0184 BCR-ABL IS % (MR-2). Area under the receiver operating characteristic curve for IPL-1 was 0.565 and IPL-2 was 0.639. For IM level at second point of 1800 ng/ml, the specificity for predicting MMR was 81.8% and sensitivity was 31.6%. Conclusion: Monitoring of trough IM plasma concentrations may become the part of standard management of CML patients.

Diagnostic Dilemma in a 70-Year-Old Man with Fever and Air-fluid Level on Chest X-ray.

Infected bullae are frequently confused with a pulmonary abscess. There recognition is important to avoid unnecessary interventions. We describe a case of 70 years male patient, who came with complaints of breathlessness since 5 years, cough with a moderate amount of mucopurulent expectoration, pain in back and right shoulder and low-grade intermittent fever all since 20 days. Past history was unremarkable. There is a history of 100 pack-years. On examination, he was tachypneic, having oxygen saturation of 87% on room air. On respiratory examination; the finding was consistent with emphysema with right sided cavitary disease. Chest X-ray showed thin walled cavity with fluid level in the right upper zone with pneumothorax on the left side. Investigations revealed 17, 000 white blood cell with neutrophil predominance. He was not responding adequately so high-resolution computed tomography (HRCT) was ordered which showed multiple thin-walled bullae in both lung along with air-fluid level in one large bullae with surrounding pneumonitis on the right side. Infected emphysematous bullae should be suspected when a fluid level appears in a patient with clinical finding suggestive of emphysema. We propose that symptomatic patients with radiological signs of air-fluid level should be evaluated with HRCT to rule out similar condition and assessment of underlying condition.