Patients with primary refractory or relapsed acute myeloid leukemia who are not eligible for standard chemotherapy and do not carry an FLT3 mutation represent a distinct therapeutic challenge. Treatment selection in this setting is guided by prior therapy received and individual patient factors.
The patient has primary refractory or relapsed AML, has been determined ineligible for standard chemotherapy, and is FLT3 mutation-negative. The optimal approach depends on which agents were used in first-line treatment, risk stratification, and patient-specific considerations including marrow cellularity and overall treatment tolerance.
The therapeutic strategy pivots on what was administered in first line. Hypomethylating agents and low-dose cytarabine are sequenced according to initial therapy. For patients who cannot tolerate or decline available options, cytoreductive supportive treatments are considered.
If the patient is considered ineligible, azacitidine or decitabine should be applied if LDAC was given in first line, and LDAC may be applied in favourable- and intermediate-risk patients if an HMA was given initially [IV, B] (Figure 3).
Older patients with hypocellular marrow may benefit from oral low-dose melphalan [V, C].
Best supportive care with cytoreductive treatment (hydroxycarbamide, 6-mercaptopurine) should be offered for patients who cannot tolerate or who decline other treatments.
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