American Society of Hematology releases new guidelines for treating AML in older adults

Based on World Bank estimates,7% of the population of low- and middle-income countries are now aged 65 years or above, with the global proportion within this age range increasing by 50% since 1980, making the optimal care of older adults with AML a growing international concern.

According to Mikkael A. Sekeres and associates, the primary goals of these guidelines are to review, critically appraise, and implement evidence-based recommendations that answer critical questions regarding managing older adults with AML, mirroring real-time practitioner-patient conversations and disease natural history.

The target audience includes patients, hematologists, general practitioners, internists, other clinicians, and decision-makers. Policymakers who may be interested in these guidelines include those involved in developing local, national, or international plans to provide optimal management of older AML patients, including those no longer receiving antileukemic therapy. This document may also serve as the basis for adaptation by local, regional, or national guideline panels.

Forming a multidisciplinary guideline panel that included specialists in myeloid leukemia, geriatric oncology, patient-reported outcomes and decision-making, frailty, epidemiology, and methodology, as well as patients, ASH used the GRADE (McMaster Grading of Recommendations Assessment, Development, and Evaluation) approach to make the new recommendations.

The recommendations cover a wide range of modalities ranging from mirroring real-time practitioner-patient conversations, the decision to pursue antileukemic treatment vs. best supportive management, the intensity of therapy, the role and duration of post-remission therapy, combination vs. monotherapy for induction and beyond, duration of less-intensive therapy, and the role of transfusion support for patients no longer receiving antileukemic therapy.

Main recommendations include-

Recommendation 1

For older adults with newly diagnosed AML considered candidates for intensive antileukemic therapy, the ASH guideline panel suggests intensive antileukemic therapy over less-intensive antileukemic therapy (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯).

Recommendation 2.

For older adults with newly diagnosed AML considered candidates for intensive antileukemic therapy, the ASH guideline panel suggests intensive antileukemic therapy over less-intensive antileukemic therapy (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯).

Recommendation 3.

For older adults with AML who achieve remission after at least a single cycle of intensive antileukemic therapy and who are not candidates for allogeneic hematopoietic stem cell transplantation (HSCT; allo-HSCT), the ASH guideline panel suggests postremission therapy over no additional therapy (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯).

Recommendation 4a.

For older adults with AML considered appropriate for antileukemic therapy but not for intensive antileukemic therapy, the ASH guideline panel suggests using either of the options when choosing between hypomethylating-agent monotherapy and low-dose-cytarabine monotherapy (conditional recommendation based on moderate certainty in the evidence of effects ⊕⊕⊕◯).

Recommendation 4b.

For older adults with AML considered appropriate for antileukemic therapy (such as hypomethylating agents [azacitidine and decitabine] or low-dose cytarabine) but not for intensive antileukemic therapy, the ASH guideline panel suggests using monotherapy with 1 of these drugs over a combination of 1 of these drugs with other agents (conditional recommendation based on low certainty in the evidence of effects.

Recommendation 5.

For older adults with AML who achieve a response after receiving less-intensive therapy, the ASH guideline panel suggests continuing therapy indefinitely until progression or unacceptable toxicity over stopping therapy (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯).

Recommendation 6.

For older adults with AML who are no longer receiving antileukemic therapy (including those receiving end-of-life care or hospice care), the ASH guideline panel suggests having red blood cell (RBC) transfusions be available over not having transfusions be available (conditional recommendation based on very low certainty in the evidence of effects). There may be rare instances where platelet transfusions may be of benefit in the event of bleeding, but there are even less data to support this practice and it is anticipated that platelet transfusions will have little or no role in end-of-life or hospice care (⊕◯◯◯).

'These guidelines are not intended to serve or be construed as a standard of care. Clinicians must make decisions based on the clinical presentation of each patient, ideally through a shared process that considers the patient's values and preferences concerning the anticipated outcomes of the chosen option, 'wrote the authors.

PRIMARY SOURCE: Blood Advances

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