Acute myeloid leukaemia (AML)

• A special type with a high risk of bleeding at the start, so it is treated as an emergency.
• Treated with ATRA (a vitamin A tablet) and arsenic trioxide, without standard chemotherapy for most patients. More than 9 out of 10 patients are cured.

For example NPM1 mutation (without other high-risk changes), or core binding factor changes [t(8;21), inv(16)]. Good chance of cure with chemotherapy.

For example TP53 mutation, complex chromosome changes, or AML following earlier chemotherapy or MDS. A transplant is usually advised if fit.

A complete blood count and a look at the blood under the microscope (peripheral smear). Often the first sign of the disease.

A small sample from the hip bone under local anaesthesia (aspiration and biopsy). Confirms AML.

Identifies the type of blast cells (myeloid or lymphoid).

Bleeding and clotting problems (DIC) are common at diagnosis, especially in APL, and are corrected with blood products.

Tissue typing of the patient and brothers and sisters, early, in case a bone marrow transplant is needed.

Before starting chemotherapy, immunotherapy or targeted therapy, these tests check that you are fit for treatment, and give a starting point to compare with later.

Before immunotherapy, also:

Sometimes needed, depending on your treatment:

• Pregnancy test for women who could be pregnant.
• Calcium and magnesium: for example before cisplatin or bone-strengthening injections.
• Dental check-up before bone-strengthening injections (zoledronic acid or denosumab), as they can rarely affect the jaw bone.
• Hearing test before cisplatin, in some patients.
• Clotting tests (PT/INR) before a biopsy or chemoport.

Your doctor will choose the tests that apply to you. Some of them are repeated during treatment.

• Some results (FLT3, and APL testing) come within days and change the first treatment, so we wait for them.
• Others (full genetic panel) can come during the first week of treatment and guide later decisions such as transplant.
• If APL is suspected, ATRA is started immediately, even before confirmation, because of bleeding risk.

Good chance of cure with chemotherapy alone.

A transplant is often considered in first remission if fit.

Higher risk of relapse; a transplant is usually advised if fit.

1. Induction (about 4 to 6 weeks in hospital): cytarabine for 7 days with daunorubicin or idarubicin for 3 days ("7+3"), with:
   • Midostaurin or quizartinib if FLT3 mutated.
   • Gemtuzumab ozogamicin for favourable-risk AML.
2. A bone marrow test to check for remission.
3. Consolidation for favourable (low) risk: 3 to 4 cycles of high-dose cytarabine.
4. For intermediate or adverse risk: allogeneic stem cell (bone marrow) transplant in first remission, after 1 or 2 cycles of consolidation.
5. Maintenance for some: oral azacitidine, or a FLT3 inhibitor.

Side effects: intensive chemotherapy · transplant

1. Azacitidine (injections for 7 days each month) with venetoclax tablets.
2. Treatment continues as long as it works. Can often be given largely as an outpatient.
3. Targeted options: ivosidenib for IDH1, gilteritinib for FLT3.

Side effects: azacitidine and venetoclax

1. ATRA with arsenic trioxide for low and intermediate risk, for about 8 months.
2. High-risk APL: chemotherapy is added at the start.
3. Blood products to control bleeding in the first days.

Side effects: ATRA and arsenic

1. Gilteritinib for FLT3 mutation; ivosidenib or enasidenib for IDH mutations; newer menin inhibitors for NPM1 or KMT2A changes.
2. Further chemotherapy, then transplant if possible.

• Very low blood counts for 3 to 4 weeks: high risk of infection, so you stay in hospital. Fever is treated as an emergency with antibiotics.
• Many blood and platelet transfusions.
• Mouth sores, nausea, hair loss, loose stools.
• Daunorubicin can affect the heart (echo is checked).

• Low blood counts and infections, especially in the first 2 cycles.
• Nausea and constipation.
• Tumour lysis (salts released when leukaemia cells break down): fluids and blood tests at the start.

• Differentiation syndrome: fever, breathlessness, swelling or weight gain in the first weeks. Report at once; it is treated with steroids.
• Arsenic: ECG changes; potassium and magnesium are kept normal.
• Headache with ATRA.

• High-dose treatment, then donor stem cells; several weeks in hospital.
• Graft-versus-host disease (donor cells attacking the body: skin rash, loose stools, liver) and infections are the main risks.
• Close follow-up for months.

• Wash hands often; avoid crowds and people with coughs or fever when counts are low.
• Eat freshly cooked, hot food; avoid raw salads, cut fruit from outside, and street food during low counts.
• Keep the central line or PICC clean and dry, as taught.
• Vaccines (such as flu and pneumococcal) as advised; avoid live vaccines during treatment.

Family and friends can help by donating blood and platelets at the hospital blood bank.

Fever of 38°C or more, bleeding (gums, nose, urine, black stools), new breathlessness, severe headache, or confusion need urgent care.

When to seek help urgently