Question 4: Should older adults with AML considered appropriate for antileukemic therapy but not for intensive antileukemic therapy receive gemtuzumab ozogamicin, low-dose cytarabine, azacitidine, 5-day decitabine, or 10-day decitabine as monotherapy or in combination?
Recommendation 4a: Based on moderate certainty in the evidence of effects, the guideline panel suggests the use of either option when choosing between hypomethylating agents and low-dose cytarabine for monotherapy.
Recommendation 4b: Based on low certainty in the evidence of effects, the panel also suggests that patients who are eligible for antileukemic therapy, but not for intensive antileukemic therapy, should use monotherapy with 1 of these drugs over a combination of 1 of these drugs with other agents. In addition, the panel authors noted that for patients who choose to use a combination therapy, low-dose cytarabine with glasdegib, or hypomethylating agents in combination with venetoclax have the most evidence of effectiveness.
Question 5: Should older adults with AML who received less-intensive antileukemic therapy and who achieved a response continue therapy indefinitely until progression/toxicity or be given therapy for a finite number of cycles?
Recommendation 5: Based on very low certainty in the evidence of effects, the authors suggest the indefinite continuation of therapy until progression or unacceptable toxicity over stopping therapy.
Question 6: Should older adults with AML who are no longer receiving antileukemic therapy (including those receiving end-of-life or hospice care) receive red blood cell transfusions, platelet transfusions, or both, vs no transfusions?
Recommendation 6: Based on very low certainty in the evidence of effects, the panel suggests the red blood cell transfusions be available vs not available for patients who no longer receive antileukemic therapy. The authors also noted that there are rare cases where platelet transfusions may be beneficial in a bleeding event, but there is not enough data to support this practice. Platelet transfusions in these instances will have little or no role in end-of-life or hospice care.
In an email interview, Courtney DiNardo, MD, MSCE, clinical researcher, department of leukemia, Division of Cancer Medicine, and Abhishek Maiti, MBBS, fellow in leukemia, at The University of Texas MD Anderson Cancer Center in Houston, discussed the developments and challenges associated with treating older patients with AML.