Myelodysplastic Syndromes: Treatment by Risk

Myelodysplastic Syndromes: Treatment by Risk: overview

This algorithm stratifies treatment of myelodysplastic syndromes by IPSS-R risk. For lower-risk disease (IPSS-R low or intermediate), therapy is directed at cytopenias and disease features. Patients with symptomatic anemia and a low EPO level receive an erythropoiesis-stimulating agent, patients with ring sideroblasts receive luspatercept (COMMANDS), and patients with del(5q) receive lenalidomide. In the site's COMMANDS summary, luspatercept achieved nearly twice the rate of transfusion independence plus hemoglobin response compared with epoetin alfa in ESA-naive, transfusion-dependent lower-risk MDS, supporting it as a preferred first-line erythropoietic therapy.

For higher-risk disease (IPSS-R high or very high), the chart shows a hypomethylating agent as disease-modifying therapy (AZA-001) and allogeneic stem cell transplant, labeled as the only curative option.

Trials behind this algorithm

COMMANDS Platzbecker U et al, Lancet, 2023; PMID: 37311468

Background reading: MPN and MDS summary board review notes.

Myelodysplastic Syndromes: Treatment by Risk: the algorithm in words

Starting point: Myelodysplastic syndromes (MDS). Full background: MPN and MDS summary notes.

Lower-risk (IPSS-R low/int) (first-line): Anemia, low EPO: Erythropoiesis-stimulating agent (symptomatic anemia); Ring sideroblasts: Luspatercept (COMMANDS); del(5q): Lenalidomide (del(5q)).
Higher-risk (IPSS-R high/very-high) (first-line): Disease-modifying: Hypomethylating agent (AZA-001); Curative: Allogeneic transplant (only curative option).