NCCN Guidelines for Patients® | Myelodysplastic Syndromes
44 NCCN Guidelines for Patients ® : Myelodysplastic Syndromes, 2018 5 Treatment guide Lower-risk MDS with anemia Guide 6. Next treatment options for lower-risk MDS with anemia Prior treatment Next treatment options • Epoetin alfa ± G-CSF • Darbepoetin alfa ± G-CSF ª • Lenalidomide + epoetin alfa ± G-CSF • Lenalidomide + darbepoetin alfa ± G-CSF • ATG (equine) + cyclosporine ª • Azacitidine • Decitabine • Consider lenalidomide • Clinical trial • Azacitidine • Decitabine • Consider lenalidomide • Clinical trial ª • Clinical trial • Consider allogeneic HCT for certain patients Guide 6 shows the next options for if prior treatment didn’t work, stopped working, or had very bad side effects. There are several options to choose from. Which option is best for you depends on the treatment you had before. Your doctor will give tests during treatment to check how well it’s working. If tests show a treatment response, you will stay on that treatment as long as it is working well. It will be stopped once it is no longer working well. Or, it may be stopped early if side effects get very bad. If one treatment doesn’t work or has to be stopped, a different option will be tried. Each time this happens, refer to the chart for the next options. These options are also described next. After treatment with epoetin alfa or darbepoetin alfa, your doctor may consider giving lenalidomide with epoetin alfa or darbepoetin alfa. This treatment is considered if there is no response, after 3 months or loss of response, to epoetin alfa or darbepoetin alfa. ESAs may be given alone or along with G-CSF. G-CSF is a white blood cell growth factor. Studies show that adding G-CSF can improve how well ESAs work for some patients. After treatment with ATG (equine) or cyclosporine, there are three main options to choose from next. The first option is to receive low-intensity chemotherapy with azacitidine or decitabine. The second option is to receive lenalidomide, unless you have a very low number of platelets or neutrophils. The third option is to join a clinical trial. After treatment with azacitidine, decitabine, lenalidomide, or a clinical trial, there are two main options to choose from next. The first option is to receive treatment within a clinical trial. An allogeneic HCT may also be an option for some patients. But, it is only recommended for patients with intermediate- risk MDS and very low blood cell counts. Next steps If tests show progression to higher-risk MDS, see Guide 8 on page 46 for treatment options. Guide 8 also includes options for treatment with an allogeneic HCT. For detailed treatment of anemia, see Guide11 on page 50.