Targeted therapy in the form of selective tyrosine kinase inhibitors (TKI) has transformed the approach to management of chronic myeloid leukemia (CML) and dramatically improved patient outcome to the extent that imatinib is currently accepted as the first-line agent for nearly all patients presenting with CML, regardless of the phase of the disease. Impressive clinical responses are obtained in the majority of patients in chronic phase; however, not all patients experience an optimal response to imatinib, and furthermore, the clinical response in a number of patients will not be sustained. The process by which the leukemic cells prove resistant to TKIs and the restoration of BCR-ABL1 signal transduction from previous inhibition has initiated the pursuit for the causal mechanisms of resistance and strategies by which to surmount resistance to therapeutic intervention. ABL kinase domain mutations have been extensively implicated in the pathogenesis of TKI resistance, however, it is increasingly evident that the presence of mutations does not explain all cases of resistance and does not account for the failure of TKIs to eliminate minimal residual disease in patients who respond optimally. The focus of exploring TKI resistance has expanded to include the mechanism by which the drug is delivered to its target and the impact of drug influx and efflux proteins on TKI bioavailability. The limitations of imatinib have inspired the development of second generation TKIs in order to overcome the effect of resistance to this primary therapy. ( Chronic myeloid leukemia (CML) results from the balanced translocation of c-ABL from chromosome 9 and BCR on chromosome 22 leading to the formation of BCR-ABL1 chimeric oncoprotein, the product of the BCR-ABL1 hybrid gene, with constitutive tyrosine kinase activity (1, 2). Deregulated BCR-ABL1 activity results in enhanced cellular proliferation, and resistance to apoptosis and oncogenesis (3, 4). CML naturally progresses through distinct phases from early chronic phase to an intermediate accelerated phase followed by a terminal blast phase. Imatinib, the first tyrosine kinase inhibitor (TKI) approved for the treatment of CML (5), is a phenylaminopyridimine, which principally targets the tyrosine kinase activity of BCR-ABL1, exclusively binding to BCR-ABL1 in the inactive conformation in addition to inhibitory effects on KIT, ARG, and PDGFR kinases (6). The recent update of the phase III randomized IRIS study (International Randomized Study of Interferon-α plus Ara-C versus STI571) prospectively comparing imatinib with interferon-α and cytarabine in previously untreated patients in first chronic phase showed the best observed rate for a complete cytogenetic response [CCyR; or an undetectable number of Philadelphia chromosome positive (Ph+) chromosomes by conventional metaphase analysis] on imatinib of 82% at 6 years (7), with a declining annual rate of progression as the molecular response improved with time.