A real-world study of infectious complications of venetoclax combined with decitabine or azacitidine in adult acute myeloid leukemia

Prognostic impact of fever at presentation in acute myeloid leukemia: a retrospective cohort study

Fever at presentation is a common clinical feature in acute myeloid leukemia (AML), yet its prognostic significance before chemotherapy initiation remains unclear. This retrospective, population-based study analyzed 198 AML patients in southern Israel from 2013 to 2023. Fever was present in 28.3% of patients and was associated with higher one-year (53.5% vs. 45.1%, p = 0.030) and five-year mortality rates (67.8% vs. 57.0%, p = 0.017). Multivariable analysis showed that fever ≥38 °C increased one-year mortality risk (OR 1.39, 95% CI 1.06-2.58, p = 0.05), rising to 1.93 for fever ≥39 °C (95% CI 1.17-2.95, p = 0.02). Median event-free survival was shorter in febrile patients (HR 1.63, 95% CI 1.14-2.35, p = 0.008), with greater association at fever ≥39 °C (HR 2.08, 95% CI 1.23-3.53, p = 0.006). Fever's prognostic association varied by age and infection status. These findings suggest that fever at presentation may serve as a clinical marker of poor prognosis in AML, warranting closer monitoring and tailored management to improve outcomes.

Economic Burden of Intravenous Decitabine Administration in Patients Affected by Acute Myeloid Leukemia Ineligible for Induction Chemotherapy and Impact of Oral Formulation Introduction: A Micro-Costing Study in Italy

Purpose

Intravenous (IV) decitabine is a therapeutic option for patients with newly diagnosed acute myeloid leukemia (AML) ineligible for induction chemotherapy. Recently, the oral formulation of decitabine-cedazuridine demonstrated comparable efficacy and safety to IV decitabine, and pharmacokinetic equivalence. This study estimates the direct non-drug healthcare costs of IV decitabine administration in Italy, including central venous catheter (CVC) and infection management, and assesses the economic impact of oral decitabine introduction.

Methods

A micro-costing analysis from the Italian National Health Service (NHS) perspective was developed in four steps: 1) identification of the phases of IV and oral decitabine administration process, including CVC and infection management; 2) estimation of resource consumption, frequencies and proportion of patients for each phase; 3) collection of unit costs; 4) development of a cost analysis model. Inputs were retrieved from literature, public sources, IQVIA proprietary databases and a panel composed of clinicians, nurses and hospital pharmacists working in oncology departments. Two scenarios were explored: the first applying the economic impact to the population of interest over three years, the second including the cost of blood transfusions.

Results

The analysis estimated a total non-drug administration cost per patient of € 3574.6 and € 781.4 for a treatment course with IV and oral decitabine, respectively, leading to a cost impact of oral drug introduction of - € 2793.2 (-78.1%). The first scenario estimated a total saving for the Italian NHS of € 1.09 million over three years, the second scenario estimated a potential additional impact of - € 3418.6/patient due to transfusions.

Conclusion

The administration of oral versus IV decitabine is expected to generate cost savings for the Italian NHS in terms of drug administration, CVC and infection management, in patients with AML ineligible for induction chemotherapy.

A systematic review of venetoclax for the treatment of unfit AML patients in real-world: is all that glitters gold?

Acute myeloid leukemia (AML) is an aggressive hematological disease that mainly affects elderly patients. Following the randomized VIALE-A trial, current standard treatment in patients who are not candidates for intensive chemotherapy consists of the combination of venetoclax (VEN), a selective inhibitor of the anti-apoptotic protein BCL-2, with azacitidine (AZA) or decitabine (DEC). We performed a systematic review to critically assess the growing existing evidence regarding the effectiveness of the VEN-based combinations in unfit adult patients with newly diagnosed AML in the real-world setting. Following PRISMA guidelines, a systematic search of published manuscripts and conference abstracts (European Hematology Association and American Society of Hematology) was conducted (updated March 2024). Primary outcomes were composite complete remission (CRc) and median overall survival (mOS). A total of 73 studies fulfilled inclusion criteria, with a median age of 73 years old. The weighted mean mOS was 10.3 months among 7 138 patients, significantly lower than expected according to the VIALE-A trial (14.7 months), while the weighted mean CRc rate was 58.2% among 5 831 patients, slightly lower to that reported in the VIALE-A (66.4%). Early death rates at 30 and 60 days were 5% and 13%, respectively. The weighted mean percentage of subsequent allogeneic transplant was 15.4%. In conclusion, breakthrough mOS reported in the VIALE-A trial using VEN-AZA was not well reproduced in real world for unfit newly diagnosed AML patients, while CRc rates were more consistent. Strategies to optimize patient selection, dosing regimens, and supportive care are crucial to improve outcomes in real-world.

Clinical Pharmacology and Side Effects of Venetoclax in Hematologic Malignancies

Venetoclax is a first-in-class B-cell lymphoma/lymphoma-2 (BCL-2) inhibitor that induces apoptosis in malignant cells through the inhibition of BCL-2. The clinical response to venetoclax exhibits heterogeneity, and its sensitivity and resistance may be intricately linked to genetic expression. Pharmacokinetic studies following doses of venetoclax (ranging from 100 to 1200mg) revealed a time to maximum observed plasma concentration of 5-8 hours, with a maximum blood concentration of 1.58-3.89 μg/mL, and a 24-hour area under the concentration-time curve of 12.7-62.8 μg·h/mL. Population-based pharmacokinetic investigations highlighted that factors such as low-fat diet, race, and severe hepatic impairment play pivotal roles in influencing venetoclax dose selection. Being a substrate for CYP3A4, P-glycoprotein, and breast cancer resistance protein, venetoclax undergoes primary metabolism and clearance in the liver, displaying low accumulation in the body.The significance of dose modifications (a 50% decrease with moderate and a 75% reduction with strong CYP3A inhibitors) and a cautious two-hour interval when co-administered with P-glycoprotein inhibitors are highlighted by insights from clinical medication interaction studies. Moreover, an exposure-response relationship analysis indicates that venetoclax exposure significantly correlates not only with overall survival and total response rate but also with the occurrence of ≥ 3-grade neutropenia. In real-world studies, common or severe side effects of venetoclax include tumor lysis syndrome, myelosuppression, nausea, diarrhea, constipation, infection, autoimmune hemolytic anemia, and cardiac toxicity, among others. In this review, we summarize the current clinical pharmacology studies and side effects of venetoclax, which showed that the approved dosage of venetoclax is relatively wide, and the dosage for different hematologic populations can be streamlined in the future.

Azacitidine in combination with shortened venetoclax treatment cycles in patients with acute myeloid leukemia

The combination of venetoclax with hypomethylating agents is currently the standard of care for elderly patients with acute myeloid leukemia (AML) ineligible for intensive chemotherapy. Despite its favorable efficacy, clinical use is often associated with post-remission cytopenia, frequently necessitating treatment delays and dose modifications. This study aims to evaluate the efficacy and safety of shortened venetoclax treatment durations. A multicenter analysis was conducted involving 20 adult AML patients receiving venetoclax (7 or 14 days with 9 and 11 patients, respectively) combined with 5-azacitidine (5-7 days) between 2021 and 2024. The cohort included patients from four German academic centers all treated in first line. Outcome measures included bone marrow response, transfusion dependence, overall survival (OS) and progression-free survival (PFS). Median age was 73.5 years, with 70% of patients having secondary AML. Adverse molecular risk was observed in 75% of patients. The overall response rate (ORR) was 100%, with a composite complete remission rate of 78%. No significant differences in response rates were observed between the 7-day and 14-day venetoclax regimens. Median OS for the cohort was 15 months. Infection-related complications were observed in 55% of patients, with severe sepsis in 20% of cases. In this cohort, shortened venetoclax regimens demonstrated efficacy comparable to standard treatment protocols, with a potential reduction in hematologic toxicity. These findings support the individualization of treatment regimens to optimize clinical outcomes while potentially minimizing adverse effects.

Safety and infection risk factors in elderly acute myeloid leukemia patients undergoing induction therapy with venetoclax combined with hypomethylating agents

OBJECTIVE

To retrospectively analyze the incidence of infections in elderly acute myeloid leukemia (AML) patients undergoing induction therapy with venetoclax combined with hypomethylating agents and to compare these findings with those from patients receiving standard or low-dose chemotherapy.

METHODS

Medical records of 169 elderly (≥60 years old) AML patients diagnosed via MICM (morphology, immunology, cytogenetics, and molecular genetics) at the First Affiliated Hospital of USTC between June 2019 and June 2022 were reviewed. Patients were divided into three groups: venetoclax combined with hypomethylating agents group (targeted therapy group), standard chemotherapy group, and low-dose chemotherapy group. Comparisons were made across groups regarding bacterial infection rates, fungal infection cases, infection sites, and severity.

RESULTS

The median ages at diagnosis in the targeted therapy group, standard chemotherapy group, and low-dose chemotherapy group were 73, 68, and 71 years, respectively (P<0.05). Compared with the standard chemotherapy and low-dose chemotherapy groups, the targeted therapy group had a higher prevalence of comorbidities (P<0.05). Complete remission rates in targeted therapy group, standard chemotherapy group, and low-dose chemotherapy group were 68.8%, 51.2%, and 26.4%, respectively (P<0.05). The durations of neutropenia were 9.0±8.4, 15.0±15.0, and 9.3±9.1 days, respectively (P<0.05). Bacterial infection rates were 87.5%, 95.2%, and 94.3% (P<0.05), with the most common sites being the lungs, bloodstream, upper respiratory tract, and unspecified sites. The durations of fever were 2.34±3.59, 4.52±4.38, and 3.53±4.76 days, respectively (P<0.05). The proportions of patients receiving antifungal prophylaxis were 46.8%, 46.4%, and 41.5%, respectively (P>0.05), mainly involving voriconazole and posaconazole. The proportions of clinically diagnosed or confirmed fungal infections were 6.3%, 9.5%, and 9.4%, respectively (P>0.05). The proportions of patients requiring initiation of antifungal therapy were 34.4%, 48.8%, and 43.4%, respectively (P<0.05). Among the 169 elderly AML patients, three (1.8%) developed infection-induced multiple organ dysfunction syndrome (i-MODSE), all in the standard chemotherapy group.

CONCLUSION

Venetoclax combined with hypomethylating agents shows a favorable safety profile and reduced infection risk in the treatment of AML in the elderly patients. Meanwhile, nontargeted therapies, a prolonged duration of neutropenia, and a prolonged duration of fever were found to be independent risk factors for fungal infections and the need for antifungal intervention.

Reduced duration and dosage of venetoclax is efficient in newly diagnosed patients with acute myeloid leukemia

OBJECTIVES

The combination of Venetoclax (VEN) and Azacitidine (AZA) increases survival outcomes and yields excellent responses in patients with acute myeloid leukemia (AML). However, dose reduction (or discontinuation) is commonly encountered due to therapy-related toxicity. Thus, this study aimed to investigate the efficiency and safety of a lower dosage of venetoclax for the treatment of AML.

METHODS

This observational study analyzed the characteristics and outcomes of newly diagnosed AML patients who received 100 mg VEN combined with AZA for 14 days at our institution.

RESULTS

A total of 36 patients were enrolled, and the median age at diagnosis was 64 years. After a median follow-up of 15 (range 4-29) months, the median overall survival (OS) and progression-free survival (PFS) for the whole cohort were 17 (4-29) months and 12 (1-28) months, respectively. Meanwhile, the overall response rate (ORR) was 69.4%, and the CRc rate was 66.7% in the whole cohort. Subgroup analysis revealed that NPM1 mutations and FAB-M5 subtype were associated with higher response rates, whereas the adverse ELN risk group was predictive of an inferior response. Moreover, ASXL1, NPM1, and IDH1/2 mutations negatively impacted PFS.

DISCUSSION

Our study optimized the administration of venetoclax plus azacytidine for the treatment of AML patients. Response rates were favorable, with median survival in agreement with the findings of earlier reports, offering valuable insights for optimizing VEN-based regimens.

CONCLUSION

In summary, the VEN combination regimen is effective for the treatment of newly diagnosed AML patients in the real world despite VEN dose reductions .

Capnocytophaga sputigena Tonsillitis in a Patient With Acute Myeloid Leukemia

Capnocytophaga sputigena is a gram-negative facultatively anaerobic, capnophilic bacterium typically residing in the human oropharyngeal flora. This opportunistic pathogen can cause a wide range of infections, from bacteremia to septic abortion. However, it is exceedingly rare for a patient to present with tonsillitis due to C. sputigena. Herein, we discuss the presentation, hospital course, and clinical trajectory of a patient experiencing complications of tonsillitis related to C. sputigena in the context of acute myeloid leukemia. Additionally, we delve into the treatment approaches and challenges in managing this particular pathogen.

Effective venetoclax-based treatment in relapsed/refractory multiple myeloma patients with translocation t(6;14)

Introduction: The selective Bcl-2 inhibitor venetoclax has shown promising therapeutic potential in multiple myeloma, particularly in cases associated with t(11;14) IGH::CCND1 translocation. However, the efficacy of venetoclax in myeloma patients with the t(6;14) IGH::CCND3 translocation remains less investigated. Methods: In this study, we conducted a retrospective analysis to investigate the efficacy of venetoclax-based therapy in relapsed/refractory myeloma patients with t(6;14) translocation. The treatment courses of three patients, that included previous therapies and responses to venetoclax, were assessed. Clinical data, laboratory results, and adverse events were analyzed to evaluate treatment outcomes. Results: Our findings demonstrated remarkable therapeutic responses in three consecutive patients with t(6;14) translocation-associated myeloma who received venetoclax-based therapy. Patient 1, a lenalidomide-bortezomib-daratumumab and alkylator treatment refractory patient, achieved sustained stringent complete remission (sCR) after combining carfilzomib-dexamethasone with venetoclax, which was his best response ever. Similarly, Patient 2, refractory to frontline bortezomib-thalidomide-dexamethasone therapy, attained CR following a transition to bortezomib-dexamethason-venetoclax treatment. Patient 3, who was immunomodulatory (IMID)-intolerant, showed a highly favorable response to venetoclax-dexamethasone therapy after his first relapse following autologous stem cell transplantation. No significant adverse effects were observed in any of the patients. Discussion: Our study provides compelling preliminary evidence for the efficacy of venetoclax in t(6;14) translocation-associated myeloma. The outcomes observed in our patients suggest that venetoclax-based therapy holds substantial promise as an effective treatment option for this specific genetic subgroup. Furthermore, the similarities in treatment response between t(11;14) and t(6;14) translocation subgroups highlight the importance of personalized approaches targeting specific genetic abnormalities to optimize therapeutic outcomes.

Pulmonary infections in patients with acute myeloid leukemia receiving frontline treatment with hypomethylating agents

Pulmonary infections (PIs) are a major complication of Acute Myeloid Leukemia (AML) treated with hypomethylating agents (HMA). We retrospectively evaluated 147 AML patients treated frontline with HMA in 2 Centers. Total number of HMA cycles was 1397. There were 88 episodes of PI in 64 patients (43.5%). Thirty-five/147 patients at risk (23.8%) developed at least 1 episode of early PI (during cycles 1-2). Median OS in patients who developed early PI was 3.3 months (95% CI 0.8 - 5.8) versus 10.5 months (95% CI 8.4 - 12.7) in patients without PI or with PI beyond the 2nd cycle (p < .001). Early PIs were an independent factor predicting lower survival (OR 1.94, 95% CI 1.28 - 2.93; p = .002). In conclusion, early PIs are common in AML patients receiving HMA and are associated with an unfavorable outcome. The results of our study raise the issue of a tailored infection prevention strategy.

Acute Myeloid Leukemia with NPM1 Mutation and Disseminated Leukemia Cutis: Achievement of Molecular Complete Remission by Venetoclax/Azacitidine Combination in a Very Old Patient

We describe a case of acute myeloid leukemia with NPM1 mutation and disseminated leukemia cutis in a very old patient, who achieved a long-lasting response to the azacitidine/venetoclax combination with molecular complete remission, given the potential value of this rarely observed clinical outcome.