COVID-19 and Acute Myeloid Leukemia: Frequently Asked Questions
Please review ASH's disclaimer regarding the use of the following information. The FAQs available on this page are not being regularly updated. The information contained herein is only accurate as of the date listed, which represents the last time the information was reviewed by experts. For the latest information on COVID-19 treatments, please review ASH’s COVID resources; previously available resources can be accessed via the archives.
(Version 1.5; last reviewed January 19, 2022)
Input from Martin Tallman, MD; Christoph Rollig, MD, MSc; Patrizia Zappasodi, PhD; Gary Schiller, MD; Gabriel Mannis, MD; Rebecca Olin, MD; Selina Luger, MD, FRCPC; and Mary-Elizabeth Percival, MD.
Note: Please review ASH's disclaimer regarding the use of the following information.
Are you changing your approach to induction therapy?
Because newly diagnosed AML is considered treatment-emergent in most cases, intensive induction chemotherapy should still be offered for eligible patients with 7+3 or similar. If lower-intensity therapy (such as hypomethylating agents + venetoclax) is considered an option, some practitioners would recommend this treatment over 7+3 to minimize transfusions and utilization of inpatient beds. Outpatient induction can be pursued if possible, though safety of inpatient vs. outpatient care for neutropenic AML patients is not known. Follow up visits can be performed by videoconferencing when possible. Prophylactic antimicrobials for patients with prolonged neutropenia should include levofloxacin, posaconazole, and acyclovir. Recommend testing all patients for COVID-19 prior to initiation of induction, regardless of regional infection rates. Recommend testing all patients for COVID-19 prior to any hospital admission and/or procedure, even in the absence of symptoms. In the setting of neutropenic fever with no other source or with abnormal chest radiology findings, consider testing for COVID-19 twice at least 12 hours apart to rule out true infection. Consider delaying treatment if possible for patients who test positive for COVID-19.
Are you changing your recommendations for consolidation therapy?
Consolidation/post-remission therapy with high-dose cytarabine should continue to be offered to patients in complete remission, but consider decreasing the number of cycles to 3 instead of 4 and/or lowering the dose of cytarabine to 1.5g/m2 instead of 3g/m2. Consolidative allogeneic hematopoietic cell transplantation is still limited at some institutions; when it is offered, cryopreservation of donor cells prior to the start of conditioning is now frequently used, which may require an extra cycle of consolidation. Recommend testing for COVID-19 prior to initiation of consolidation. Recommend testing all patients for COVID-19 prior to any hospital admission and/or procedure even in the absence of symptoms. In the setting of neutropenic fever with no other source or with abnormal chest radiology findings, consider testing for COVID-19 twice at least 12 hours apart to rule out true infection.
How are you treating patients with relapsed/resistant leukemia?
Many clinical trials have slowed or decreased enrollment, so standard regimens are recommended if clinical trials are unavailable. Salvage intensive re-inductions are still considered, but the potential benefit must be weighed against the hardship for patients given the prolonged hospital stay and the restriction on visitors. Local/regional blood product supply should also be considered. For patients without proliferative disease or significant transfusion dependence, therapy may be temporarily postponed. Some centers are continuing to prioritize clinical trials for this patient population.
Do any of the leukemia drugs interact with COVID-19 potential therapies?
Giving chemotherapy in the face of a known COVID-19 infection seems very high risk. Consider drug interactions due to CYP3 inhibition or potential QT prolongation especially when drugs such as venetoclax or gilteritinib are used.
Are you making any changes to growth factor support or transfusion thresholds for AML patients?
Consider lowering current transfusion thresholds due to current or predicted shortages in blood bank supply, while recognizing that there is considerable local/regional variability. For patients without symptomatic anemia or bleeding complications, consider decreasing the hemoglobin threshold to 7 g/dl and the platelet threshold to 10,000/microliter. Strongly consider use of growth factors to decrease duration of neutropenia and risk of febrile neutropenia requiring hospitalization. Consider anti-fibrinolytics for patients requiring frequent platelet transfusion and/or platelet-transfusion-refractory patients.
Should APL be treated differently in the COVID-19 era?
Low-risk APL patients should be treated with ATRA and ATO as per standard treatment, though consider delaying addition of ATO to potentially decrease the risk of differentiation syndrome. High-risk APL patients should be treated with cytoreduction in addition to ATRA and ATO as per standard treatment. Patients at high risk of differentiation syndrome can also be treated with prophylactic dexamethasone, but the increased lymphopenia is of unknown risk in relation to COVID-19.
Should I give a SAR-CoV-2 vaccine to my patient with AML?
In general, it is considered safe and appropriate for patients with AML to receive vaccines, as long as they are not live, attenuated virus vaccines. Specific to SARS-CoV-2, data regarding the safety and efficacy of vaccines in immunocompromised patients have not yet been released. As a general statement we support giving people with AML undergoing treatment the SARS-CoV-2 vaccine (non-live) although they may not mount an effective immune response, but await trial results. For more information, please view the FAQ on SARS-CoV-2 vaccines and immunocompromised patients.
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