Best Practices for the Management of Acute Myeloid Leukemia

In a Pharmacy Times® Practice Pearls series titled “Considerations in the Treatment of Acute Myeloid Leukemia,” Katie Culos, PharmD, BCOP, a hematology/oncology clinical pharmacist at Vanderbilt University Medical Center in Nashville, Tennessee; Amanda Brahim, PharmD, BCOP, BCPS, BCACP, a hematology/oncology clinical pharmacist at Memorial Cancer Institute in Pembroke Pines, Florida; and Yehuda Deutsch, MD, a hematologist/oncologist in the Department of Malignant Hematology and Cellular Therapy at Memorial Cancer Institute, discussed considerations in the treatment for patients with acute myeloid leukemia (AML), the most frequently occurring cause of acute leukemia in adults.

The virtual series centered around treatments for patients with AML in both inpatient and outpatient formularies, particularly at the Memorial Cancer Institute. AML is associated with specific chromosomal abnormalities that include translocations, rearrangements, environmental exposures to carcinogens, as well as previous chemotherapy, radiation, or immunosuppressant therapy. There are also special considerations for signs and symptoms.

“[AML] is categorized by bone marrow failure, with a range of signs and symptoms with fatigue, bleeding, sometimes we’ll see white blood counts that are higher or lower than the normal range. All of those signs and symptoms that patients present with are because of that bone marrow failure,” Brahim said.

Although patients with AML require treatment somewhat immediately, health care providers will often wait for test results before initiating the treatment. They often look for abnormalities in the blood cell count, which requires a complete count before treatment can begin.

“We often see in the CBC the hemoglobin anemia, low platelets, and the white blood cell count can be high or low. [We are] looking at a blood smear to determine what type of white blood cells are there. Another test we often do from the peripheral blood would be a flow cytometry test, which is able to identify the type of abnormal cells and try to identify the population of myeloblast of the leukemia cell,” Deutsch said.

Deutsch added that patients are often referred when testing has not been conducted, but that additional testing may be done by the center due to the importance of cytogenetic and molecular mutation in the diagnosis of AML. The cytogenetic and molecular samples are collected with bone marrow biopsy and aspiration. Should providers be unable to collect samples through these methods, they can do so through the peripheral blood. Cytogenetic analysis or chromosomal analysis must be completed, as must molecular testing with next-generation sequencing or polymerase chain reaction.

Additionally, health care providers must be aware of the patient’s medical history, such as diet, exercise, age, gender, etc, but also the support they may have from their friends and family, as treatment often requires patients to be transported back and forth between outpatient visits.

“It’s not just the age of the patient, but the fitness. We look at their comorbidities, those with more have a higher risk of complications. We also look at patients’ family and support system. You need access to get to a medical, hospital facility and when you are home you need that social support as well,” Deutsh said.

Brahim explained that Memorial Cancer Institute has a specific, patient-wide hematology and oncology pharmacy and therapeutics committee, comprised of a multi-disciplinary team of physicians, pharmacists, advanced practice providers, and nurses. Their current formulary includes gemtuzumab ozogamicin, cytarabine and daunorubicin [CPX-351], and midostaurin (Rydapt), which is used on the inpatient side for patients receiving standard 7 + 3 chemotherapy but who have a FLT3 mutation. Venetoclax (Venclexta) is also available with midostaurin in case of immediate need for therapy.

Variation in oral agents for outpatient formulary is a bit more liberal, according to Brahim.

“If there is evidence and it follows a good logic and fits into our AML treatment pathway overall, those agents are approved. We try to work with insurance companies [and] we do have a specialty pharmacy within our health system. So, we are able to keep things in-house and have a bit more control over things like prior authorization processes,” Brahim said.

According to Brahim, traditional 7+3 chemotherapy is still entirely inpatient at Memorial Cancer Institute, and patients receiving CPX-351 can either be inpatient or outpatient, depending on the patient’s strength. Newer oral agents are generally prescribed in an outpatient setting.

Memorial Cancer Institute developed a setting known as inpatient/outpatient (IPOP), because the patients are able to come in as outpatients and go home at the end of the day. Additionally, the center is located next to the inpatient unit, has nursing care similar to that of the inpatient setting, and the pharmacy support is there as well. The center has approximately 16 beds and infusion suite chairs in the facility.

“Many of these patients will have fevers, and many of them will have to get admitted to the hospital, but they’re basically already in the hospital,” Deutsch said. “They can be directly admitted—we can have hospitalists come and see them, sometimes other specialists, and any scans or tests that need to be done can be done immediately there.”

The value of the outpatient setting in treatment of AML serves as an opportunity to improve quality of life while affording pharmacists more opportunities for patient-centered care. Through this setting pharmacists have direct contact with the patient throughout their treatment.

“Patients need more education. They need constant reinforcement of different concepts. Having a daily touchpoint with a pharmacist about diet, drug interactions, etc, is really helpful for patients. As we’re following the patients, different things come up. Families get involved. This is where a pharmacist’s input can be helpful,” Brahim said.