So, um, like in my practice, you know, we usually consider um chemotherapy for patients who have peripheral T cell lymphomas in the frontline setting, but as I mentioned, there's a large group of these patients that may relapse or have primary refractory disease. And given that the currently available. Agents, um, like giving, you know, single agent Roadsin or single agent bilinostat or single agent Prilatrexate or even single agent rituximab for TFH phenotype lymphomas has a, you know, uh, a response rate of, you know, 25 to 30% or so. Um, I do consider giving Duvaliib, um, in, um, the second line because the response rate in peripheral T cell lymphoma NOS is about 50% in the Primo study and the response rate in AITL is um almost 62% in the Primo study. Um, and, uh, for us, you know, when we consider seeing these patients, really the goal is to get them, if they're allo transplant. to get them to an aloe transplant and to try to get them there as soon as possible because we only have windows of opportunity of remission to achieve a good enough remission to then send them to an aloe transplant. But multiple studies have now shown that um for patients who are able to get to an aloe transplant, they're of adequate performance status, they're of adequate age, um, they have a donor, they have the right support to go through an aloe transplant. Um, about 50 or 60% of these patients will be alive long term with consolidated and allogeneic transplant. And so for me, if you're able to get patients into a complete remission quickly, um, with relatively meager minimal toxicity, that's really the goal. And so we often will use Duvali which has a, you know, 1/3 of the patients will have a complete remission. We have considered giving patients combination treatment with Duvalui plus um other agents like Romodepsin. We consider that for some of our more fit patients. I have to admit that our patients um here at WashU in St. Louis are predominantly older. They often are traveling from a long distance and they have difficulty at you know, um, getting regular infusions and the regimens of using Duvali plus Romodpsin require weekly infusions. Um, just like the, um, the package insert for Romosin, and so that, um, that makes that sometimes a little bit challenging for many of our patients. I think some of the other challenges that our patients face is, um, when we try to get Duvali approved, um, there's some difficulty, um, in, um, in patients who end up having a high copay but are not eligible for co-pay assistance programs and so that can serve as a challenge. Getting Duvaliip to patients and then certainly we try to apply for 75 mg BID um as their initial dose um but because the CLL approval for Duvali has been 25 mg BID, um, sometimes, um, uh, insurance payers will only, um, cover the 75 mg BID. Oftentimes with letter and appeals, we're able to get the higher dose, but it doesn't happen 100% of the time.
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