Low risk MDS with anemia

 low-risk MDS patients with anemia warranting treatment options:

No Ring Sideroblasts

Is Epo level <100?

• First Line: ESA
• Second Line: Either add lenalidomide or switch to Luspatercept
• Third Line: Luspatercept if not already used
• Fourth Line: Imetelstat

Is Epo level >100 <500?

• Consider first-line Luspatercept here (given ESA is less likely to work)
• Move to Imetelstat if failure with Luspatercept

Ring Sideroblasts

• First Line: Luspatercept. There is much clearer data for efficacy here.
• Second Line: Move to Imetelstat

If failure/lack of response despite further moving down this list, then hypomethylating agents as are used for higher-risk MDS.