Current Evidence and Clinical Algorithms for Targeted Management of Polycythemia Vera: Applying Trial Insights to Patient Care
Panelists discuss how polycythemia vera treatment follows a risk-stratified approach, with all patients receiving daily aspirin and phlebotomies to maintain hematocrit below 45%, while high-risk patients (aged >60 years or history of thromboembolism) additionally require cytoreductive therapy with options including hydroxyurea, pegylated interferon alfa-2a, ropeginterferon alfa-2b, or second-line ruxolitinib, with treatment modifications based on response, tolerance, and disease progression.
Summary of Polycythemia Vera Management Algorithm
Low-Risk Polycythemia Vera (PV) Management
- Universal measures for all PV patients:
- Low-dose aspirin (baby aspirin) daily for thromboembolic prophylaxis
- Phlebotomy to maintain hematocrit <45%
- Monitoring requirements:
- New thrombosis or bleeding events
- Development of indications for cytoreductive therapy
- Indications to escalate to cytoreductive therapy:
- New thrombotic event
- Disease-related bleeding
- Progressive symptoms
- Progressive splenomegaly
- Frequent phlebotomies (≥4 per year)
High-Risk PV Management
- Definition of high-risk:
- Aged >60 years, OR
- Prior history of thromboembolic event, OR
- Both factors
- Treatment approach:
- Daily low-dose aspirin
- Mandatory cytoreductive therapy
- Target hematocrit <45%
Cytoreductive Therapy Options
- First-line options:
- Hydroxyurea
- Pegylated interferon alfa-2a
- Ropeginterferon alfa-2b
- Second-line options:
- Ruxolitinib (FDA-approved for second-line use)
- Alternative cytoreductive agent not used in first line
- Indications for switching cytoreductive therapy:
- Loss of response
- Continued need for phlebotomies despite high-dose therapy
- Intolerance to current agent
This treatment algorithm emphasizes the primary treatment goal of thrombosis prevention through hematocrit control and platelet inhibition, with risk-adapted cytoreductive therapy selection for high-risk patients and those with disease complications.
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