Management Strategies for Hydroxyurea-Resistant PV: Treatment Optimization and Evidence-Based Second-Line Selection
Panelists discuss how to approach a 67-year-old man with advanced polycythemia vera who is resistant to hydroxyurea, requiring frequent phlebotomies despite maximum tolerated dosing, and experiencing new symptoms like night sweats and fatigue.
In this segment, the experts discuss a 67-year-old man with advanced polycythemia vera (PV) who initially presented with headaches and dizziness. Despite treatment with phlebotomies, aspirin, and maximum tolerated hydroxyurea (2 g daily), the patient continues to require frequent phlebotomies and has developed new symptoms including night sweats and fatigue. Laboratory findings show hemoglobin of 15.5, hematocrit of 47%, platelet count of 380, and white blood cell count of 13.
Dr. Rampal outlines the treatment goals for PV: reducing thrombosis risk, decreasing disease progression risk, and alleviating symptoms. He notes that keeping hematocrit below 45% is crucial for thrombosis prevention, and elevated white blood cell count also increases thrombosis risk. Based on the persistent need for phlebotomies despite high-dose hydroxyurea and worsening symptoms, Dr. Rampal concludes that the current treatment is failing this patient.
Dr. Vachhani emphasizes that PV is a tri-lineage condition affecting all blood cell types, and while hematocrit control has historically been the focus, white blood cell and platelet counts are also important considerations. Multiple studies have shown correlation between elevated white blood cell counts and increased thrombosis risk. The experts agree that this case meets the definition of hydroxyurea resistance, which necessitates consideration of second-line therapies to achieve better disease control and symptom management.
