Myelodysplastic Syndrome (MDS)

Regimen Options

Last Updated: 05/21/2026 See Details

REVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM (IPSS-R): VERY LOW, LOW, INTERMEDIATE

	Evolent Pathways	Febrile Neutropenic Risk	Emetogenic Risk	References
REVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM (IPSS-R): VERY LOW, LOW, INTERMEDIATE - SYMPTOMATIC ANEMIA WITH NO DELETION (5Q)
Initial Therapy	epoetin alfa if marrow blasts less than 10%; Serum EPO less than 500mU/mL	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
Subsequent Therapy	azacitidine or decitabine failure of ESA, EPO greater than 500, Or greater than one line of cytopenia; Not for use in combination with epoetin	Low	Moderate	NCCN Guidelines® for Myelodysplastic Syndromes V.1.2018. Fenaux P, et al. Lancet Oncol. 2009;10(3):223-32. Lyons RM, et al. J Clin Oncol. 2009;27(11):1850-6.
	epoetin alfa if marrow blasts less than 10%; Serum EPO less than 500mU/mL; combination therapy for failure of single agent epoetin	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NEUPOGEN® (filgrastim) injection, for subcutaneous or intravenous use. Initial U.S. Approval: 1991. FDA Label. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
	epoetin alfa and filgrastim if marrow blasts less than 10%; Serum EPO less than 500mU/mL; combination therapy for failure of single agent epoetin	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NEUPOGEN® (filgrastim) injection, for subcutaneous or intravenous use. Initial U.S. Approval: 1991. FDA Label. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
Maintenance Therapy	epoetin alfa	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NEUPOGEN® (filgrastim) injection, for subcutaneous or intravenous use. Initial U.S. Approval: 1991. FDA Label. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
	epoetin alfa and filgrastim	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NEUPOGEN® (filgrastim) injection, for subcutaneous or intravenous use. Initial U.S. Approval: 1991. FDA Label. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
REVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM (IPSS-R): VERY LOW, LOW, INTERMEDIATE - SYMPTOMATIC ANEMIA WITH DEL(5Q) ± OTHER CYTOGENETIC ABNORMAILITES
Initial Therapy	lenalidomide	Low	Low	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NCCN Guidelines® for Myelodysplastic Syndromes V.1.2018. List A, et al. N Engl J Med. 2006;355(14):1456-64. Raza A, et al. Blood. 2008;111(1):86-93.
Subsequent Therapy	epoetin alfa If marrow blasts less than 10%; Serum EPO less than 500mU/ml	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NEUPOGEN® (filgrastim) injection, for subcutaneous or intravenous use. Initial U.S. Approval: 1991. FDA Label. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
	epoetin alfa and filgrastim If marrow blasts less than 10%; Serum EPO less than 500mU/ml	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NEUPOGEN® (filgrastim) injection, for subcutaneous or intravenous use. Initial U.S. Approval: 1991. FDA Label. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
	azacitidine or decitabine	Low	Moderate	NCCN Guidelines® for Myelodysplastic Syndromes V.1.2018. Fenaux P, et al. Lancet Oncol. 2009;10(3):223-32. Lyons RM, et al. J Clin Oncol. 2009;27(11):1850-6.
Maintenance Therapy	epoetin alfa	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NEUPOGEN® (filgrastim) injection, for subcutaneous or intravenous use. Initial U.S. Approval: 1991. FDA Label. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
	epoetin alfa and filgrastim	Not Applicable	Not applicable	NCCN Drugs & Biologics Compendium® Myelodysplastic Syndromes (MDS) V.1.2018. NEUPOGEN® (filgrastim) injection, for subcutaneous or intravenous use. Initial U.S. Approval: 1991. FDA Label. EPOGEN® (epoetin alfa) injection, for intravenous or subcutaneous use. Initial U.S. Approval: 1989. FDA Label.
REVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM (IPSS-R): INTERMEDIATE, HIGH, VERY HIGH
High-Intensity Therapy Candidate	azacitadine or decitabine	Low	Moderate	NCCN Guidelines® for Myelodysplastic Syndromes V.1.2018. Fenaux P, et al. Lancet Oncol. 2009;10(3):223-32. Lyons RM, et al. J Clin Oncol. 2009;27(11):1850-6.
	Transplant	Not Applicable	Not applicable	NCCN Guidelines® for Myelodysplastic Syndromes V.1.2018.
Not High-Intensity Therapy Candidate	azacitadine or decitabine	Low	Moderate	NCCN Guidelines® for Myelodysplastic Syndromes V.1.2018. Fenaux P, et al. Lancet Oncol. 2009;10(3):223-32. Lyons RM, et al. J Clin Oncol. 2009;27(11):1850-6.

REVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM (IPSS-R): VERY LOW, LOW, INTERMEDIATE - SYMPTOMATIC ANEMIA WITH NO DELETION (5Q)

Initial Therapy

Evolent Pathways

epoetin alfa *if marrow blasts less than 10%; Serum EPO less than 500mU/mL*

Febrile Neutropenic Risk

Emetogenic Risk

References

Subsequent Therapy

Evolent Pathways

azacitidine or decitabine *failure of ESA, EPO greater than 500, Or greater than one line of cytopenia; Not for use in combination with epoetin*

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

Evolent Pathways

epoetin alfa *if marrow blasts less than 10%; Serum EPO less than 500mU/mL; combination therapy for failure of single agent epoetin*

Febrile Neutropenic Risk

Emetogenic Risk

References

Evolent Pathways

epoetin alfa and filgrastim *if marrow blasts less than 10%; Serum EPO less than 500mU/mL; combination therapy for failure of single agent epoetin*

Febrile Neutropenic Risk

Emetogenic Risk

References

Maintenance Therapy

Evolent Pathways

epoetin alfa

Febrile Neutropenic Risk

Emetogenic Risk

References

Evolent Pathways

epoetin alfa and filgrastim

Febrile Neutropenic Risk

Emetogenic Risk

References

REVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM (IPSS-R): VERY LOW, LOW, INTERMEDIATE - SYMPTOMATIC ANEMIA WITH DEL(5Q) ± OTHER CYTOGENETIC ABNORMAILITES

Initial Therapy

Evolent Pathways

lenalidomide

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Subsequent Therapy

Evolent Pathways

epoetin alfa *If marrow blasts less than 10%; Serum EPO less than 500mU/ml*

Febrile Neutropenic Risk

Emetogenic Risk

References

Evolent Pathways

epoetin alfa and filgrastim *If marrow blasts less than 10%; Serum EPO less than 500mU/ml*

Febrile Neutropenic Risk

Emetogenic Risk

References

Evolent Pathways

azacitidine or decitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

Maintenance Therapy

Evolent Pathways

epoetin alfa

Febrile Neutropenic Risk

Emetogenic Risk

References

Evolent Pathways

epoetin alfa and filgrastim

Febrile Neutropenic Risk

Emetogenic Risk

References

REVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM (IPSS-R): INTERMEDIATE, HIGH, VERY HIGH

High-Intensity Therapy Candidate

Evolent Pathways

azacitadine or decitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

Evolent Pathways

Transplant

Febrile Neutropenic Risk

Emetogenic Risk

References

Not High-Intensity Therapy Candidate

Evolent Pathways

azacitadine or decitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

Pathways and Low-Value Regimens

Myelodysplastic Syndrome (MDS)