Combination of 2-Chlorodeoxyadenosine, Cytarabine, and Granulocyte Colony-Stimulating Factor and Venetoclax in a Case of Acute Myelogenous Leukemia

Abstract

The high rates of relapse following induction therapy for acute myelogenous leukemia (AML) warrant the investigation of novel chemotherapy regimens to better treat the disease safely. We report a case of refractory AML treated with CLAG (a combination of 2-chlorodeoxyadenosine, cytarabine, and granulocyte colony-stimulating factor (GCSF)), as a replacement for FLAG-IDA (fludarabine, cytarabine, G-CSF and idarubicin), due to a shortage of fludarabine, plus B-cell lymphoma-2 (BCL-2) inhibitor venetoclax (CLAG + VEN). A 38-year-old woman with a past medical history of systemic lupus erythematosus (SLE), managed on hydroxychloroquine, presented to her primary care provider with worsening fatigue and was found to have significant leukocytosis. The patient was diagnosed with AML on bone marrow biopsy (BMBX). The patient delayed care after the initial diagnosis but eventually started on a continuous infusion of cytarabine for therapy day (D) 1 - D7 and daunorubicin 60 mg/m² (D1 - D3) (7 + 3) induction chemotherapy. A BMBX was performed on D18 following induction therapy, revealing residual disease with 46% blasts, indicative of refractory AML. Three weeks after completing induction therapy, the patient underwent CLAG + VEN. After completing CLAG + VEN, she was found to be minimal residual disease (MRD)-negative and was determined to be an appropriate candidate for bone marrow transplant (BMT) following maintenance therapy with Onureg (azacitidine). The patient successfully underwent BMT and remains MRD-negative 1 year post-transplant. Treatment with CLAG + VEN was effective in achieving remission in this case, enabling this patient to successfully undergo BMT. This suggests a potential therapeutic benefit of combining venetoclax with traditional CLAG therapy in complex cases of AML.