Canterbury DHB

Management of AML

Introduction and Key Questions

Key Questions:

• Is intensive treatment appropriate?
• Does the patient have APML?
• Is the patient eligible for any AML trial that may be open?

If suitable for intensive treatment:

• Have all the pre-treatment tests been done, including specific investigations required for a trial that may be considered?
• Has a Hickman central venous line been inserted or arranged?
• Has tissue typing been organised for the patient if they are of a suitable age? Experience has made us aware this often gets missed, so please ensure it gets done. Tissue typing of the family is a consultant decision once the risk factors are better defined.
• Have the required supportive care measures been organised?
• Has entry into any other relevant trials been considered?
• Has the need for sperm or ovarian storage been discussed?

The decision regarding trial entry or other treatment is made by the patient and their Consultant.

Current Trials in AML

For current trials in AML, see the Clinical Trials page on the Intranet or phone the Clinical Trials Co-ordinator (ext: 80377).

• Currently, no clinical trial for AML is actively recruiting.

Supportive Care

This is to some extent individualised depending on the type of treatment the patient is receiving. For example, it will differ during intensive chemotherapy treatment compared to any subsequent allograft procedures if they may be given.

Key Aspects of Supportive Care

• IV access - Insertion and care of Hickman or PICC/Midline for all intensively-treated patients..
• Infection prophylaxis - antifungal with posaconazole, antiviral with Valaciclovir if HSV serologically positive, protective isolation diet, isolation in single room for all intensively-treated patients.
• Prevention of urate nephropathy - In AML, give Allopurinol 300 mg orally daily if renal function is normal. Seek advice if creatinine is significantly elevated. Tumour lysis syndrome is rare even in high white count AML but management is described in the Drug Usage in Haematology section.
• Antiemetics
• Pain Management
• Psychological Support
• Blood and Platelet Transfusions
• Nutritional Support
• Management of the septic neutropenic patient
• Treatment of established or suspected bacterial, fungal, herpetic, toxoplasma, and PCP infections.

Note: PCP is uncommon with current AML treatment schedules, except for those containing fludarabine.

Emergencies in Acute Leukaemia

Complications of acute leukaemia and its treatment are an important cause of mortality and morbidity. They include:

• Neutropenic sepsis
• Tumour lysis syndrome if white count very high (relatively uncommon)
• Hyperleucocytosis (recent reviews have not shown benefit of leukapheresis)
• Methotrexate-induced stroke-like neurotoxicity. This is seen particularly in phases of treatment which include frequent intrathecal methotrexate. See Bhojwani, D., Sabin, N.D. (2014). "Methotrexate-induced neurotoxicity and leukoencephalopathy in childhood acute lymphoblastic leukemia." J Clin Oncol 32: 949-59.
• Cytarabine-induced cerebellar toxicity
• Acute promyelocytic leukaemia differentiation syndrome
• Thrombo-haemorrhagic syndrome in APML
• L-asparaginase-associated thrombosis
• Leukaemic meningitis
• Neutropenic enterocolitis
• Transfusion-associated GVHD

An expert review of managing these conditions was published in 2012. See Zuckerman, T., C. Ganzel, et al. (2012). "How I treat hematologic emergencies in adults with acute leukemia." Blood 120(10): 1993-2002.

Topic Code: 4287