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PHM 703- Oncology, Hematology > AML > Flashcards

AML Flashcards

1
Q

AML signs and symptoms

A

anemia (fatigue, SOB)
thrombocytopenia (bleeding risk)
neutropenia (ANC <500mcL or ≤1000mcL with anticipated decrease to <500mcL within 48 hours)
TLS
CNS involvement (somnolence, HA, confusion- rare)

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2
Q

What oncologic emergency (besides TLS) can occur in AML?

A

Hyperleukocytosis

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3
Q

Features of hyperleukocytosis

A

WBC ≥100K/mcL
Poor prognosis
Increases risk of CNS involvement and TLS

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4
Q

Signs/symptoms of hyperleukocytosis

A

Blood sludging, stupor, SOB, vision changes, stroke, respiratory failure, cardiac ischemia, renal failure, retinal hemorrhage possible

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5
Q

Hyperleukocytosis management

A

Hydroxyurea to kill the circulating cells to prep for induction treatment

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6
Q

Hydroxyurea AEs

A

N/V/D, watch for TLS

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7
Q

AML risk factors

A

increasing age, prior chemo, prior pelvic radiation, smoking, radiation exposure, benzene exposure, pesticide exposure, petrochemical exposure

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8
Q

AML treatment algorithm: step 1

A

Determine if the patient is a candidate for aggressive induction chemo

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9
Q

Induction chemotherapy criteria

A

Most patients <60 years
Patients ≥60 without significant comorbidities or end-organ dysfunction, good performance status
Patients with aggressive disease course (have hyperleukocytosis or TLS at presentation)
Patients who are candidates for allogeneic stem cell transplant

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10
Q

If the patient qualifies for aggressive induction chemo, what do you give them?

A

7+3 regimen (preferred), liposomal daunorubicin/cytarabine, or clinical trial

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11
Q

7+3 regimen components

A

7-day infusion of cytarabine continuous IV infusion
3 days of anthracycline bolus dose

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12
Q

Days 1-7 of chemo administration

A

N/V, GI effects, fatigue. WBC counts drop like crazy

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13
Q

Days 8-24 of chemo administration

A

AEs: fatigue, fever/infection, high RBC and platelet transfusion requirement. Infection risk begins here

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14
Q

Days 25+ of chemo administration

A

discharge from hospital once ANC >500 and no longer platelet transfusion dependent

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15
Q

Additional induction regimens: FLT3-ITD or FLT3-TKD positive

A

Midostaurin

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16
Q

Additional induction regimens: favorable/intermediate cytogenetics

A

GO

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17
Q

Additional induction regimens: secondary AML treatment

A

Liposomal daunorubicin and cytarabine

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18
Q

Step 2a: what to do when the patient qualifies for aggressive induction disease after treatment

A

do a bmbx 14 days later and assess if they’re leukemia free or not

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19
Q

Step 3a: patient is leukemia free

A

await count recovery +/- G-CSF, repeat bone marrow biopsy to document complete remission, then consolidation and consideration for bone marrow transplant if complete remission

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20
Q

Step 3b: patient is NOT leukemia free

A

re-induction or salvage therapy → if it continues, supportive care/comfort measures or consolidation and consideration for bone marrow transplant

21
Q

If the patient doesn’t qualify for aggressive induction chemo, what are your treatment options?

A

clinical trial, “low intensity chemo,” gemtuzumab ozogamicin (GO), targeted therapy (if actionable mutation) until disease progression

22
Q

Step 2b: what to do when the disease progresses

A

Supportive care/comfort measures

23
Q

Response criteria in AML

A

“Leukemia-free state”- day 14 bone marrow biopsy
Goal: <5-10% blasts, hypocellular (<10-20% cells)

24
Q

Criteria for complete remission

A

<5% blasts and ANC >1000mcL AND platelets >100K/mcL

25
Q

Post-remission therapy: what patients is it for?

A

Patients who receive intensive chemo only!

26
Q

Post-remission therapy treatment options

A

High-dose cytarabine
Liposomal daunorubicin and cytarabine
Allogeneic stem cell transplant

27
Q

Low-intensity chemo: what patients is it for?

A

Patients who are unfit for intensive chemo or those with significant comorbidities

28
Q

Low-intensity chemo options

A

Hypomethylating agents + venetoclax
Low-dose cytarabine + venetoclax

29
Q

Dose adjustments: HMAs with strong 3A4 inhibitors

A

100mg PO QD

30
Q

Dose adjustments: HMAs with moderate 3A4 or P-gp inhibitors

A

200mg PO QD

31
Q

Dose adjustments: low-dose cytarabine with strong 3A4 inhibitors

A

150mg PO QD

32
Q

Dose adjustments: low-dose cytarabine with moderate 3A4 or P-gp inhibitors

A

300mg PO QD

33
Q

Relapsed/refractory disease treatment options in AML

A

clinical trial
can repeat initial induction treatment if response lasted ≥12 months
cladribine
cytarabine
G-CSF +/- mitoxantrone
HiDAC + mitoxantrone or anthracycline
fludarabine,
G-CSF +/- idarubicin
clofarabine
GO
venetoclax-based therapies if patient didn’t receive upfront
hypomethylating agents
low-dose cytarabine
targeted therapies if actionable mutation present

34
Q

Targeted therapies in AML: FLT3 mutation

A

Midostaurin, gilterinitib

35
Q

Midostaurin indication

A

newly-diagnosed FLT3+ AML

36
Q

Gilterinitib indication

A

relapsed/refractory FLT3+ AML

37
Q

Targeted therapies in AML: IDH inhibitors

A

Ivosidenib, enasidenib

38
Q

Ivosidenib indication

A

newly diagnosed AML and relapsed/refractory AML with IDH1 mutations

39
Q

Enasidenib indication

A

relapsed/refractory AML with IDH2 mutation

40
Q

AML chemo clinical pearls: anthracyclines

A

red in color → pink/light red urine, sclera
mitoxantrone is blue in color → blue-green urine, sclera
AE: myelosuppression, cardiotoxicity (lifetime dose!!)

41
Q

AML chemo clinical pearls: cytarabine

A

neurotoxicity (cerebellar syndrome → ataxia, nystagmus, dysarthria); “neuro checks” required prior to each dose. Conjunctivitis

42
Q

AML chemo clinical pearls: GO

A

infusion-related reactions (premedicate with APAP, diphenhydramine, methylprednisolone); hepatotoxicity, including VOD → BBW!

43
Q

Supportive care in AML

A

Transfusions
Infection prophy
TLS treatment
Myeloid growth factors

44
Q

AML supportive care: when to give transfusion

A

RBC transfusion if Hgb <8mg/dl, platelet transfusion if platelets <10000/mcL

45
Q

AML supportive care: infection prophy: HSV/VZV

A

Acyclovir

46
Q

AML supportive care: infection prophy: ABX

A

ciprofloxacin 500mg BID or levofloxacin 500mg QD, amox/clav 500mg BID or PO 3rd generation cephalosporin if there’s a FQ allergy

47
Q

AML supportive care: infection prophy: invasive fungal and mold infections

A

posaconazole ER tablets 300mg BID x2 doses, then 300mg QD; voriconazole 200mg BID (will cover mold)

48
Q

AML supportive care: myeloid growth factors

A

Can be started after day 14 bmbx in those with intensive chemo treatment; used in severe infections in setting of neutropenia

PHM 703- Oncology, Hematology (15 decks)

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