Acute Myeloid Leukemia Treatment Protocols

Treatment Protocols

Treatment protocols for acute myeloid leukemia are provided below, including a general treatment approach and treatment recommendations for relapsed or refractory disease.^[1]

General treatment approach for acute myeloid leukemia

Fit patients (< 60-65 years, select patients up to age 75 y) receive intensive 

therapy

. Treatment includes induction therapy and postremission therapy (consolidation). Non – low risk-patients are evaluated for stem cell transplantation in first remission.

Less fit patients (70-75 years and older, or younger patients with significant comorbidities) receive low-intensity therapy. Select less fit patients with highly proliferative disease may be considered for intensive therapy

Treatment recommendations for patients < 60y or for select patients ≤ 75y (good performance status, minimal or no comorbidities)

Induction therapy:

Combination of cytarabine and anthracycline or anthracenedione is recommended

• Cytarabine 100-200 mg/m² continuous IV infusion for 7d plus idarubicin 12 mg/m²/day for 3dor daunorubicin 60-90 mg/m²/day for 3d
• Follow-up bone marrow to assess remission is typically done 7-14d after completion of induction chemotherapy, except for patients with acute promyelocytic leukemia (APL) (see APL guidelines)^[6]

High-dose cytarabine plus anthracycline/anthracenedione (various regimens, such as idarubicin + high-dose cytarabine)^{[7, 8]} :

• Cytarabine 2-3 g/m² q12h for 3d plus  idarubicin 12 mg/m²/day for 3d for 1 cycle or
• Cytarabine 2-3 g/m² q12h for 3d plus  daunorubicin 45-60 mg/m² day for 3d for 1 cycle^[6]

Cladribine-based therapy:

• Cytarabine 200 mg/m² continuous infusion for 7d plus daunorubicin 60 mg/m² for 3d plus cladribine 5 mg/m² for 5d^[9]
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Postremission therapy (consolidation)^{[2, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19]} :

All patients should be assessed for risk of relapse. Specific drug regimens are recommended based on a patient’s risk of relapse.

Better-risk patients:

Cytogenetics [inv(16) or t(16;16), t(8;21)] and molecular abnormalities (normal cytogenetics: with NPM 1 mutation or isolated CEBPA mutation in the absence of FLT3-ITD):

• High-dose cytarabine 3 g/m² IV over 3h every 12h on days 1, 3, and 5 for 4 cycles^[6] or
• High-dose cytarabine 3 g/m² IV over 3h every 12h on days 1, 3, and 5 for 2 cycles plus  autologous stem cell transplantation^[6]

Intermediate-risk patients:

Cytogenetics [normal cytogenetics, +8, t(9;11), other nondefined] and molecular abnormalities [normal cytogenetics: t(8;21), inv(16), t(16;16): with c-KIT mutation]:

• High-dose cytarabine 3 g/m² IV over 3h every 12h on days 1, 3, and 5 for 4 cycles or allogeneic stem cell transplantation

High-risk patients:

Cytogenetics [complex (≥ 3 clonal chromosomal abnormalities), -5, 5q-, -7, 7q-, 11q23 - non t(9;11), inv(3), t(3;3), t(6;9), t(9;22)] and molecular abnormalities (normal cytogenetics: FLT3-ITD mutation), prior antecedent hematologic disorder (AHD):

• Allogeneic stem cell transplantation or
• Clinical trial or
• High-dose cytarabine 3 g/m² IV over 3h every 12h on days 1, 3, and 5; if clinical trial not available

Treatment recommendations for patients ≥ 60y^{[20, 21, 22, 23]} :

• There is no standard therapy for this patient population; a clinical trial is preferred
• The following low-intensity therapies are recommended for patients ≥ 60y: azacytidine 75 mg/m² IV or SC for 7d every 4-5wk or decitabine 20 mg/m² IV daily for 5d every 4-5wk or low-dose cytarabine 20 mg SC BID for 10d every 4wk
• In patients with a high WBC count (especially > 30,000) who are unlikely to respond to low-intensity therapy, consider therapies as in younger patients; however, tolerance and response may be poor

Treatment recommendations for relapsed or refractory disease

• Response rates depend on duration of first remission^[24]
• Patients in complete remission (CR) longer than 2y have a 60% chance of responding to front-line regimens
• Patients in CR 1-2y have a 40% chance of responding to front-line regimens; clinical trials are preferred
• Patients in CR less than 1y are unlikely to respond to front-line regimens and should be referred for clinical trials
• The prognosis for patients beyond first salvage is very poor^[25]

Recommended chemotherapy regimens for relapsed or refractory disease:

Mitomycin, etoposide, and cytarabine (MEC)^[26] :

• Etoposide 80 mg/m² IV over 1h plus  cytarabine 1 g/m² IV over 6h plus mitoxantrone 6 mg/m²; all 3 drugs should be given daily for 6d or

CLAG-M (cladribine, cytarabine, mitoxantrone, and filgrastim)^[27] :

• Cladribine 5 mg/m² IV over 2h daily for 5d plus  cytarabine 2 mg/m² IV over 4h daily for 5d, with each dose starting 2h after cladribine plus  mitoxantrone 10 mg/m² IV for 3d plus filgrastim 300 µg for 6d starting 24h prior to chemotherapy or

FLAG-IDA (fludarabine, cytarabine, idarubicin, and filgrastim)^[28] :

• Fludarabine 30 mg/m²/day IV over 30min on days 1-5
• Cytarabine (Ara-C) 2 g/m²/day IV over 4h; 4h after fludarabine on days 1-5
• Idarubicin 10 mg/m²/day IV on days 1-3
• Filgrastim (Neupogen) 5 µg/kg/day SC to begin on day 6 until neutrophil recovery