Algorithm for treatment choice in MDS patients after failure of HMA therapy. Reasoned choice of second- and third-line treatment options after HMA therapy based on clinical and biological characteristics of the patient. In this setting, experimental trials are recommended; the experimental agents indicated in the figure are those evaluated in the highest number of cases. *Off-label use; on-label use of lenalidomide (LEN) only in del5q; thrombopoietin (TPO) mimetics in experimental trials. AZA, azacitidine; chemo, chemotherapy; DAC, decitabine; PS, performance status.