the scenes Pediatric oncology Mathias Buaas Austli Clinical pharmacist Background 5 year old boy Acute myloid leukemia Treatment according to NOPHODBH AML 2012 ID: 1048059
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1. Clinical primetimeBehind the scenesPediatric oncologyMathias Buaas AustliClinical pharmacist
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6. Background5 year old boyAcute myloid leukemiaTreatment according to NOPHO-DBH AML 2012First Allogenic stemcell transplant full engraftment Relapse of disease 9 months post transplant
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8. Treatment of relapse AML in pediatricsPatient has FLT3-ITD positive AMLHigh-risk diseaseSensitive to FLT3 inhibitor?
9. Treatment planBrunner AM, Li S, Fathi AT, et al. Haematopoietic cell transplantation with and without sorafenib maintenance for patients with FLT3-ITD acute myeloid leukaemia in first complete remission. Br J Haematol. 2016;175(3):496-504. doi:10.1111/bjh.14260Rautenberg C, Nachtkamp K et al. Sorafenib and azacitidine as salvage therapy for relapse of FLT3-ITD mutated AML after allo-SCT. Eur J Haematol. 2017 Apr;98(4):348-354. doi: 10.1111/ejh.12832. Epub 2017 Feb 2. PMID: 27893163.Sorafenib pediatric formulation?Azacitidine administration in pediatrics? Start of treatment 1 Month2 Months3 Months4 MonthsSorafenib100 mg Twice dailyAzacitidine7 daysAllogenic stemcell transplant
10. Sorafenib treatmentDose 100mg morning 100mg evening
11. Azazitidine treatment Dose 75mg once daily7 day course with 3 week intervals Difficult logistics Superior patient care
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13. Good tolerance of treatment for 4 monthsPlanned start of allogenic stemcell transplant Admitted to hospital with clinical symptoms of heart failure No earlier history of heart disease Recived antracyclines in primary AML treatment Treatment related?
14. Cardiotoxicity of sorafenibStart of treatment 1 Month2 Months3 Months4 MonthsSorafenib100 mg Twice dailyAzacitidine7 daysAllogenic stemcell transplantOn-set of Cardiotoxicity Developes neutropenic feverAdmitted to local hospital:Start antibiotic therapy + Posaconazol
15. Treatment of Heart faliureACE inhibitorDiuretics Discontinuation of Sorafenib and PosaconazoleComplete regeneration of heart function in 14 daysNormal Eccocardiogram Normal proBNP Cardiologist approval for continuing to allogenic stemcell transplant
16. Second Allogenic stemcelltransplant Matched unrelated donor (10/10 match)7 day conditioning Treosulfan 14g/m2 for 3 daysFludarabine for 5 daysThiotepa 1 dayGvHD prophylaxisAnti-ThymoglobulinCiclosporinPost-Tx Methotrexate
17. Parenteral NutritionMorphineParacetamolMeropenemChallenges: To few IV access pointBlood and platelet transfusions ?
18. Post transplant follow-upDay 60 bone marrow complete remission of AMLHigh relaps potential!Quick discontinuation of immunosupressive therapyPost transplant AzacitidineDonor lymfocyte infusionPotential Midostaurin treatment
19. 1 year post transplantStill complete remission Started schoolPlays basketball
20. What have i learned?