AML

 Initial management

Identifying the 5 main life threatening situations associated with AML

1.  Tumor lysis: IV fluids, allopurinol, test for G6PD def, rasburicase
2.  DIC: fibrinogen > 150 using cryo
3.  Neutropenic sepsis: CXR, UA, broad spectrum antibiotics
4.  Bleeding: pRBC, plt leukoreduced, irradiated ( if transplant eligible)
5.  Hyperleukocytosis: hydroxyurea

Additional work up on admission: Echo, triple lumen, HLA typing of patient, bone marrow bx, skin bx.

20% blast count is no longer required for diagnosis of AML with recurrent genetic abnormalities except biallelic CEBPA mutation.

Risk stratification

ELN 2022 for standard therapy in younger individuals

ELN 2024 for lower intensity rx such as  AZA- Ven. 

• TP53 mutated--> poor
• KRAS, NRAS, LFT 3 ITD without TP53--> intermediate
• All others - beneficial

TRM calculator Fred Hutch 

https://trmcalculator.fredhutch.org/

Infections in CAR- T

 

 

Prophylaxis Post CAR-T infections

Prophylaxis     Preferred Drugs       Alternate          Start     End

1.       Antibacterial (with Pseudomonas coverage)           

a.       Preferred: Fluoroquinolones (Levofloxacin 500mg PO daily)

b.       Alternate: Cefpodoxime 200mg PO BID      

c.       Start with: Onset of neutropenia (ANC < 500/mm3)           

d.       Stop when: Recovery of neutropenia (ANC > 500/mm3)

2.       Antiviral (for HSV/VZV prevention)   

a.       Preferred Acyclovir 400-800mg PO BID       

b.       Alternate: Valacyclovir 500mg PO daily, Famciclovir 250mg PO BID              

c.       Start with lymphodepletion  Continue until CD4 counts > 200 or at least 6 months

3.       Antifungals     

a.       Preferred Fluconazole 200mg PO daily (standard risk).  Posaconazole 300mg PO daily          

b.       Alternate: Micafungin 50 IV q24H (if LFT abnormality)       

c.       Start with Onset of neutropenia (ANC < 500/mm3)            

d.       Stop when: Recovery of neutropenia (ANC > 500/mm3)

4.       Antifungals in high risk * (high risk= mold coverage for patients with prior fungal infection, and/or high dose corticosteroids)

a.       Voriconazole 200mg PO two times a day, Posaconazole 300mg PO daily

b.       Start of high dose steroids, other risk factors          

c.       Mold prophylaxis for 1 month after completion of Immune suppressive therapies

5.       Anti-PJP pneumonia

a.       Trimethoprim/Sulfamethoxazole 1 double-strength PO three times a week.

b.       Alternate: pentamidine 300 mg monthly inhaled. Dapsone 100 mg PO daily. Atovaquone 1500 mg PO daily     

c.       Start: Day 28 

d.       Stop: Continue at least 3 months, until CD4 > 200/uL

6.       Hepatitis B carriers/exposed ( HBs Ag positive or Anti-HBc Ab IgG positive)

a.       Entecavir                                       

b.       Start At least 6 months and surveillance of LFT and HBV DNA as indicated.