Palliative Care
Early referral to the Palliative Care Service is very important.
Low dose cytarabine as per AML14 trial
- The AML14 trial was a randomised phase III trial for patients with AML or High Risk Myelodysplastic Syndrome (MDS) (>10% blasts), for patients aged over 60 years of age. The aim of the AML14 trial was to compare two strategies of treatment for patients with Acute Myeloid Leukaemia (AML) or High Risk Myelodysplastic Syndrome (MDS) and to compare treatment options within these two strategies. The non-intensive arm compared hydroxyurea with low dose cytarabine.
- Results for non-intensive arm. The AML14 trial stopped early as there was a better survival with low dose cytarabine (6% survival with low dose cytarabine compared with 1% survival with hydroxyurea at 3 years).
- Give Cytarabine 20 mg BD by subcutaneous injection daily on days 1–10 (20 doses) to be repeated at approximately 28 day intervals. In some patients it may be necessary to extend the intervals to up to 42 days. A minimum of 4 courses should be administered if tolerated and then continued indefinitely while the patient is tolerating it. Sometimes 7 day courses are better tolerated. The data indicates that patients with poor risk disease are less likely to go into remission on this regimen. However, this regimen, like hydroxyurea, may help control the height of the blast count.
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Etoposide/Thioguanine
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Schedule
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Etoposide (VP16)
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50 mg Daily PO
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Thioguanine
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40 mg Daily PO
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- The dose of one or both can be doubled if a quicker response is required.
- Administer for 7-10 days, and then assess response.
- If renal function is abnormal and/or raised uric acid level, consider administering allopurinol, 100 to 200 mg daily, depending on the degree of renal dysfunction.
Hydroxyurea
Hydroxyurea on a daily basis (up to 3–4 g orally per day) can also be valuable, especially:
- in patients whose blast count increases rapidly after discontinuing etoposide and thioguanine, or
- as an initial treatment for patients with high white counts before, for example, entering into AML19.
Hyperleucocytosis
Recent reviews have not shown a benefit of leukapheresis for patients with very high white counts.
Reference
Oberoi S, Lehrnbecher T, Phillips B, Hitzler J, Ethier M-C, Beyene J, et al. Leukapheresis and low-dose chemotherapy do not reduce early mortality in acute myeloid leukemia hyperleukocytosis: A systematic review and meta-analysis. Leukemia Research. 2014 April;38(4):460-68.
Topic Code: 4295
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