patient care perspectives

Principles of Supportive Care for AML

by Harry Paul Erba, MD, PhD

Overview

Although patients with acute myeloid leukemia (AML) may experience neutropenia, anemia, or thrombocytopenia, supportive care measures are available to help them maintain functionality.

Expert Commentary

Harry Paul Erba, MD, PhD

Instructor
Director, Leukemia Program
Medical Director, Hematologic Malignancies Inpatient Service
Division of Hematologic Malignancies and Cellular Therapy
Department of Medicine
Duke Cancer Institute
Duke University School of Medicine
Durham, NC

“In terms of the neutropenia, I tell my patients that this is not a good time to clean the black mold out of their showers or to do mulching or composting in their backyards, for example. But when patients ask if they can go outside and take a walk with a friend, my answer is ‘absolutely’ because I do not want them to be too isolated.” 

Harry Paul Erba, MD, PhD

Supportive care is important for maintaining functionality and quality of life. What can we do for the neutropenia, anemia, and thrombocytopenia of AML? In terms of the neutropenia, while good personal hygiene and handwashing are critical, neutropenia should not prevent patients from going outside or eating a regular diet. In fact, Gardner and colleagues demonstrated that a neutropenic diet, compared with a non-neutropenic diet, did not improve response rates, infection rates, survival, or hospitalizations in patients admitted to a protected environment to receive induction therapy for newly diagnosed AML. Further, the elimination of green leafy vegetables from a patient’s diet may have deleterious consequences (eg, constipation, which could result in microtears and bacteremia). I tell my patients that this is not a good time to clean the black mold out of their showers or to do mulching or composting in their backyards, for example. But when patients ask if they can go outside and take a walk with a friend, my answer is “absolutely” because I do not want them to be too isolated.

One controversial topic is the use of prophylactic antibiotics in patients with neutropenia. In my practice, I generally initiate a prophylactic fluoroquinolone antibiotic and a prophylactic broad-spectrum azole antifungal in patients at risk for prolonged neutropenia (>1 week) for those periods of neutropenia. However, prophylaxis should be guided by the microorganisms that are prevalent in the community and the types of infections that are commonly seen in practices.

Another area of complexity is the use of growth factors. Although granulocyte colony-stimulating factor added to induction or consolidation therapy has not demonstrated a survival benefit in AML, consideration should be given to its use in select circumstances (eg, in patients who are in remission with their hypomethylating agent and venetoclax treatment but are still experiencing prolonged myelosuppression). To date, there are no data from randomized clinical trials of AML or myelodysplastic syndrome showing that myeloid growth factors cause disease progression or increase the risk of relapse. With regard to platelets, we have not used growth factors in AML for thrombocytopenia. They have been studied more in myelodysplastic syndrome, where concerns related to bone marrow fibrosis and progression to AML are prominent. I will administer prophylactic platelet transfusions in patients with platelet counts of less than 10,000/µL or in those who have overt signs of bleeding or mucosal bleeding. It is not clear whether there is a benefit of multiple platelet transfusions in a single day for those who do not have those overt signs of bleeding.

For patients who require blood transfusions, I consider how they feel at a specific hemoglobin (Hgb) level when assessing the need for transfusion. A patient may feel vastly different at an Hgb level of 7 g/dL than they would at an Hgb level of 9 g/dL. Additionally, all patients should receive leukocyte-depleted blood products to reduce the risk of febrile transfusion reactions, alloimmunization, and cytomegalovirus transmission. While all patients do not require irradiated blood products, they are recommended for those who may be transplant candidates because they can prevent transfusion-associated graft-versus-host disease.

References

Cannas G, Thomas X. Supportive care in patients with acute leukaemia: historical perspectives. Blood Transfus. 2015;13(2):205-220. doi:10.2450/2014.0080-14

Gardner A, Mattiuzzi G, Faderl S, et al. Randomized comparison of cooked and noncooked diets in patients undergoing remission induction therapy for acute myeloid leukemia. J Clin Oncol. 2008;26(35):5684-5688. doi:10.1200/JCO.2008.16.4681

Schiffer CA, Bohlke K, Delaney M, et al. Platelet transfusion for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2018;36(3):283-299. doi:10.1200/JCO.2017.76.1734

Sekeres MA, Guyatt G, Abel G, et al. American Society of Hematology 2020 guidelines for treating newly diagnosed acute myeloid leukemia in older adults. Blood Adv. 2020;4(15):3528-3549. doi:10.1182/bloodadvances.2020001920

Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018;36(30):3043-3054. doi:10.1200/JCO.18.00374

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