Menin inhibition for the treatment of acute leukemia

Menin inhibitors are emerging as targeted therapies for acute leukemias with high HOXA gene expression. These leukemias harbor mutations including KMT2A-rearrangements, NPM1c mutations, NUP98-fusions, UBTF tandem duplications and potentially others. Mechanistically, each of these oncoproteins depend on the KMT2A:Menin interaction to maintain critical gene expression. Several Menin inhibitors have entered clinical trials and have shown impressive efficacy in heavily pretreated patients with acute myeloid leukemia (AML). Revumenib received FDA approval for patients with relapsed or refractory acute myeloid leukemia with KMT2A-rearrangements in November 2024. Despite the success of Menin inhibitors, leukemia progression due to therapeutic resistance is a common occurrence with monotherapy. Hence, current clinical trials focus on Menin inhibition in combination with chemotherapy and/or standard-of-care targeted therapies to potentially overcome or prevent resistance. Menin inhibitors are also being investigated in patients with newly diagnosed acute leukemia or as a maintenance therapy post allogeneic stem cell transplantation. This review provides an overview of the mechanism of action of Menin inhibitors and the disease subsets that show sensitivity. We explain the current understanding of genetic resistance, mediated by Menin mutations that reduce drug binding affinity, and the emerging understanding of other types of resistance. Ongoing clinical trials are summarized, and we discuss the future role of Menin inhibition as a potentially practice-changing treatment for up to 50% of patients with AML.