1. Patients who are elderly or who for some other reason are not thought to be good candidates for high-dose Ara-C chemotherapy or BMT should receive two additional cycles of induction chemotherapy after achieving remission (i.e., a total of three cycles).

2. Low risk patients should receive four cycles of high dose Ara-C, 3 gm/m2 q 12 hours 1,3,5

3. Intermediate risk patients have three options:

  1. If pt meets age criteria for BMT, with matched related donor and no contraindications to BMT: allogeneic BMT in 1st CR ± 1 cycle of HDAC consolidation prior to BMT
  2. If  pt meets age criteria for autoBMT/SCT, not allo related candidate (no donor or too old): 1-2 cycles of HDAC consolidation, followed by autoBMT/SCT
  3. Consolidation with 4 cycles of HDAC
4.High risk patients:
  1. If pt meets age criteria, with matched related donor and no contraindications to BMT: allogeneic BMT/SCT in 1st CR ± 1 cycle of HDAC prior to transplant
  2. If pt meets age criteria, no related donor: Matched unrelated donor BMT/SCT in 1st CR ± 1-2 cycles HDAC consolidation prior to transplant OR enter clinical trial for high risk AML. Consolidation cycles should begin as soon as marrow recovers from prior chemotherapy.
  3. If not eligible for allo- or MUD transplant, consolidation with 4 cycles of HDAC or other (experimental) regimen at discretion of attending
5. HLA typing for BMT candidates

6. High dose Ara-C consolidation regimen  (Calculate Body Surface Area):  Link to orders

    1. Ara-C 3 gm/m2 in 500cc D5W infused over 3 hours every 12 hours on days 1,3,5 (six total doses per cycle)
      1. Dose adjustments for renal insufficiency:
        1. Creatinine < 1.3: full dose
        2. Creatinine 1.3-1.4: 33% dose reduction (2 gm/m2)
        3. Creatinine 1.5-2.0: 66% dose reduction (1 gm/m2)
        4. Creatinine > 2.0: do not use high dose Ara-C (see above)
      2. Antiemetic regimen to include granisetron or ondansetron/dexamethasone and lorazepam (HDAC very emetogenic)
      3. Dexamethasone eye drops 2 drops OU q 6 h throughout, until four days after completing HDAC
      4. Pyridoxine 50 mg po days 1-5
      5. Neurologic assessment prior to each dose of Ara-C to evaluate for cerebellar toxicity.
        1. If there is a question of cerebellar dysfunction or other change in neurologic status, hold next dose of Ara-C. If cerebellar toxicity is present this should become clear over next 12 hours.
        2. If there is definite cerebellar toxicity, discontinue Ara-C
      6. Menstruating women should receive anovulatory agents during periods of profound thrombocytopenia.
      7. Ara-C skin toxicity (purpuric rash) can be managed with steroids if symptomatic
    2. Out-of-hospital care: Hotel accomodations for patients not requiring hospitalization can be arranged through the housing coordinator (Shawn Arneson, 3-0315)
    3. Guidelines for early discharge after HDAC consolidation:
      1. Consider discharge if patient is afebrile, not nauseated, compliant, has ready access to facility capable of delivering emergency care for neutropenic sepsis and administering transfusions, and has a caregiver available round the clock at home.
      2. Discharge medications:
        1. TMP-sulfa DS bid on Saturday & Sunday
        2. Acyclovir 400 mg bid
        3. Fluconazole 200 mg/day
        4. Anovulatory agent for menstruating women
        5. Appropriate prn antiemetics
        6. Dexamethasone eye drops until 4 days after finishing HDAC
        7. (Optional) Cipro 500 mg bid
      3. Lab monitoring: Hgb, WBC, plts qod. Add ANC when WBC > 500. Continue until ANC > 500, platelets > 20K without transfusion.
      4. Transfusions:
        1. Platelets to keep count > 20K
        2. RBC: To keep Hgb > 8.0 or for symptoms of anemia; may use higher transfusion trigger at discretion of attending for selected patients.
        3. All blood products irradiated, leukopoor, CMV negative when appropriate (for any CMV-negative patient who is potential BMT candidate). Premeds as per ward routine for individual patient.
      5. Patient education: seek immediate medical attention and notify hematologist on call for fever, rigors, bleeding, protracted nausea or vomiting. Call hematologist on call for cough, chest pain, shortness of breath, dizziness when standing, abdominal pain, or any other new or worrisome symptom. Patient's caregiver to receive same instructions when possible.
      6. Patient should receive a letter at discharge with brief medical summary, including current meds, and instructions for managing neutropenic fever and other complications of marrow aplasia.
      7. Sign out all patients to Hematology attending and fellow during period of marrow aplasia.

Reviewed November 2016