Guideline Updates

ASH Releases Guidelines for Management of Older Adults With AML

August 07, 2020

The American Society of Hematology (ASH) published evidence-based guidelines to help older adults with newly diagnosed acute myeloid leukemia (AML) and their healthcare providers make critical decisions regarding the management of their disease. These guidelines were published in Blood Advances (2020;4[15]:3528–3549. doi:10.1182/bloodadvances.2020001920).

The guidelines developed in partnership with the McMaster Grading of Recommendation Assessment, Development, and Evaluation (GRADE) Centre, offer treatment recommendations based on systematic reviews of all available evidence (up to May 24, 2019).

ASH formed a multidisciplinary guideline panel that included specialists in myeloid leukemia, geriatric oncology, patient-reported outcomes and decision-making, frailty, epidemiology, methodology, as well as patients.

The panel agreed on 6 critical questions regarding the management of older patients with AML: the decision to pursue antileukemic treatment vs best supportive management, the intensity of therapy, the role and duration of postremission therapy, combination versus monotherapy for induction and beyond, duration of less-intensive therapy, and the role of transfusion support for patients no longer receiving antileukemic therapy.

ASH labeled the recommendations as either “strong” or “conditional” according to the GRADE approach. The phrase “the guideline panel recommends” is used for strong recommendations, and the phrase “the guideline panel suggests” is used for conditional recommendations.

A summary of the treatment recommendations are as follows:

  • Recommendation 1: For older adults with newly diagnosed AML who are candidate for such therapy, the ASH guideline recommends offering antileukemia therapy over best supportive care.
  • Recommendation 2: For older adults with newly diagnosed AML considered candidates for intensive antileukemic therapy, the ASH guideline suggests intensive antileukemic therapy over less-intensive antileukemic therapy.
  • Recommendation 3: For older adults with AML who achieve remission after ≥1 cycle of intensive antileukemic therapy and who are not candidates for allogeneic transplantation, the ASH guideline suggests postremission therapy over no additional therapy.
  • Recommendation 4:
    • For older adults with AML considered appropriate for antileukemia therapy but not intensive antileukemic therapy, the ASH guideline suggests using either hypomethylating-agent monotherapy and low-dose-cytarabine monotherapy.
    • For older adults with AML considered appropriate for antileukemic therapy but not intensive antileukemic therapy, the ASH guideline suggests using monotherapy with hypomethylating agents or low-dose cytarabine rather than a combination of 1 of these drugs with other therapies.
  • Recommendation 5: For older adults with AML who achieve a response after receiving less-intensive therapy, the ASH guideline suggests continuing therapy indefinitely until progression or unacceptable toxicity over stopping therapy.
  • Recommendation 6: For older adults with AML who are no longer receiving antileukemic therapy, the ASH guideline suggests having red blood cell transfusions available over not having transfusions available.

The panel noted that these recommendations are guided by the principle that throughout a patient’s disease course, optimal care involves ongoing discussions between clinicians and patients, continuously addressing goals of care and the relative risk-benefit balance of treatment.—Janelle Bradley