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This is a combination of four tyrosine kinase inhibitors (TKIs): imatinib mesylate, dasatinib, nilotinib, and bosutinib. All four are small molecule inhibitors that target the BCR-ABL fusion protein with tyrosine kinase activity, which is the primary driver mutation in chronic myeloid leukemia (CML). Imatinib was the first TKI developed for CML and remains a standard first-line therapy. Dasatinib, nilotinib, and bosutinib are second-generation TKIs developed to overcome resistance or intolerance to imatinib; they have increased potency against BCR-ABL and can inhibit many mutant forms associated with resistance. Each drug has a distinct safety profile but shares common adverse effects such as cytopenias and gastrointestinal symptoms. These agents are approved for use in various lines of therapy for CML[1][2][5][7][9].
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