Treatment Options and Care for Patients Who Develop Therapy-Related AML - Episode 7

Supportive Care and Consolidation Therapy in AML

Rami Komrokji, MD:Obviously, during the acute phase, or the initial phase, patients need to be hospitalized. We are actually able to give the chemotherapy in the outpatient setting. Then we admit the patients into the hospital for around 3 to 4 weeks. Here, they will need regular blood transfusions. They will need monitoring for complications and onset of infection. Patients go on prophylactic antibiotics to prevent infection during that course. Once the counts recover, they are discharged to the outpatient setting. In the outpatient setting, we obviously assess response. We assess that the patient is in remission or we assess for any potential toxicity that’s persisting in the patient. Then we decide on the next step for treatment, which is what we call consolidation therapy. Here, the patient will get further chemotherapy. Sometimes they get 1 or 2 more rounds of CPX-351. Patients who are going to proceed to transplant may proceed to transplant immediately. Or, if there is a delay, they could get further consolidation—1 or 2 cycles—and then go to transplant.

When this patient presented, his white count was high. His creatinine was high. One would work to hydrate the patient and check uric acid. If it’s elevated, you could prescribe medications to lower the uric acid. And then, during the course of the treatment, patients will be on prophylactic medications to prevent infection, whether it’s viral, bacterial, or fungal. They will need blood transfusion supportive care—platelet and red blood cell transfusion. They do get a baseline cardiac evaluation. Some of them may have arrhythmias during the course of treatment, whether they are treated with 3 + 7 chemotherapy or CPX-351, so one would monitor for that. The mainstay of supportive care management is in terms of infection prophylaxis and blood products support. Some of the patients will get what we call mucositis, inflammation of the gut, or diarrhea. They will need some supportive treatment for that, as well.

Yes, this patient has therapy-related AML. It’s considered high risk, so we will evaluate this patient for the possibility of an allogeneic stem cell transplant. This will depend on how he tolerated intensive chemotherapy, his organ function testing, and the availability of a donor. But ultimately, if this patient can receive an allogeneic stem cell transplant, that’s potentially the most curative option for him.

If the patient is going to transplant, the timing of the transplant may depend on many things. On average, it takes 3 to 4 months to get to transplant. Sometimes we will do a consolidation cycle of chemotherapy before transplant. For patients who are not proceeding to transplant, we definitely plan to do consolidation therapy. In the CPX-351 study, patients were offered consolidation therapy with 1 or 2 cycles of CPX-351.

Transcript edited for clarity.

Case: A 67-Year-Old Man with Therapy-Related AML

  • A 67-year-old man who had received CHOP for diffuse large B-cell lymphoma 3 years prior
  • PMH: hypertension controlled with amlodipine
  • Laboratory results:
    • WBC 15 x 109/L
    • Serum creatinine 1.5 mg/dL
    • Normal LFTs
    • LVEF 50%
  • Diagnosis: Acute Myeloid Leukemia
  • ECOG PS 1
  • The patient received liposomal cytarabine and daunorubicin
  • His course was complicated by febrile neutropenia
  • After induction, <5% marrow blasts, neutrophil count (>1400/&micro;L), platelets 60,000/&micro;L