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Live Imaging of Antifungal Activity by Human Primary Neutrophils and Monocytes in Response to A. fumigatus
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Should patients with acute myeloid leukemia treated with venetoclax-based regimens receive antifungal prophylaxis?

Mariana Guarana1, Marcio Nucci2

  • 1University Hospital, Universidade Federal do Rio de Janeiro, Brazil.

Leukemia Research
|June 16, 2023
PubMed

Insights

Primary antifungal prophylaxis may not be necessary for acute myeloid leukemia (AML) patients on venetoclax regimens due to low invasive fungal disease (IFD) incidence. Azole drug interactions and toxicities further support avoiding prophylaxis in this AML subgroup.

Area of Science:

  • Hematology
  • Infectious Diseases
  • Pharmacology

Background:

  • Invasive fungal disease (IFD) is a significant risk for acute myeloid leukemia (AML) patients undergoing intensive chemotherapy.
  • Standard care includes anti-mold prophylaxis for intensive chemotherapy regimens.
  • The role of antifungal prophylaxis in AML patients on less-intensive venetoclax-based regimens is not well-defined.

Purpose of the Study:

  • To review risk factors for IFD in AML patients on intensive chemotherapy.
  • To assess IFD incidence and risk factors in patients on hypomethylating agents and venetoclax-based regimens.
  • To discuss azole drug interactions and toxicities, and propose management strategies for AML patients on venetoclax without primary antifungal prophylaxis.

Main Methods:

  • Literature review of risk factors for IFD in AML patients.
  • Analysis of IFD incidence in various AML treatment settings.
  • Discussion of drug interactions and toxicities associated with azole antifungals.
  • Review of current perspectives on managing AML patients on venetoclax-based regimens.

Main Results:

  • The incidence of IFD may be too low in venetoclax-treated AML patients to justify primary antifungal prophylaxis.
  • Azole antifungals require dose adjustments with venetoclax due to drug interactions.
  • Azole use is linked to toxicities such as liver, gastrointestinal, and cardiac issues (QT prolongation).

Conclusions:

  • The number needed to harm from azole prophylaxis may exceed the number needed to treat in low IFD incidence settings.
  • Management of AML patients on venetoclax-based regimens may not require primary antifungal prophylaxis.
  • Alternative strategies for IFD management in this patient population should be considered.
Keywords:
Acute leukemiaAntifungalMyeloidProphylaxisVenetoclax

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