INTRODUCTION: The aim of treatment in very low-, low- and intermediate-1-risk myelodysplastic syndrome (MDS) is mainly to relieve symptoms due to cytopenias. Only a few therapeutic drugs are currently available, but novel drugs are under clinical investigations. In this setting, imetelstat, a telomerase inhibitor, is a promising new agent. AREAS COVERED: This review summarizes promising emerging strategies using imetelstat for the treatment of lower-risk MDS. EXPERT OPINION: Favorable results were demonstrated in the IMerge phase 3 clinical trial using imetelstat in transfusion-dependent patients with lower-risk MDS relapsed or refractory to erythropoiesis-stimulating agents (ESAs). This study led to imetelstat approval by the United States Food and Drug Administration (FDA) in June 2024.