ASH 2025 treatment guidelines: ND AML in older patients

Guidelines from the American Society of Hematology (ASH) for treating newly diagnosed (ND) acute myeloid leukemia (AML) in older adults (≥55 years) were published in Blood Advances by Sekeres et al. The panel reached consensus on nine critical clinical recommendations for the management of AML in older adults, designed to reflect the nuances of real-time conversations between practitioners and patients. 

Key findings: Patients who are candidates for therapy should receive antileukemic treatment rather than best supportive care. For patients eligible for conventional induction and post-remission chemotherapy, this approach is preferred; however, hypomethylating agent / low-dose cytarabine (HMA/LDAC) combined with venetoclax may be used for older or higher-risk patients. Post-remission therapy is advised for those achieving remission and not eligible for allogeneic hematopoietic stem cell transplantation (allo-HSCT). For patients ineligible for conventional induction and post-remission therapy or HMA-based combination therapy, azacitidine monotherapy or 5-day decitabine is preferred over LDAC monotherapy or 10-day decitabine, respectively, and adding venetoclax to HMA or LDAC is recommended vs using these agents alone. Patients ineligible for conventional induction and post-remission therapy should receive azacitidine + ivosidenib or HMA + ivosidenib or venetoclax for IDH1 mutations, and azacitidine alone or HMA + venetoclax for IDH2 mutations (preferred over azacitidine + enasidenib or HMA + enasidenib, respectively). Patients should also continue HMA- or LDAC-based treatment until progression or unacceptable toxicity; receive an Fms-like tyrosine kinase 3 (FLT3) inhibitor with conventional induction and post-remission therapy if FLT3-mutated; consider allo-HSCT in first remission for nonfavorable prognosis; and have red blood cell (RBC) transfusions available if no longer on therapy.

Key learning: Nine critical clinical recommendations were included in the ASH 2025 guidelines for the treatment of ND AML in older patients (≥55 years), including guidance on choice of conventional induction and post-remission vs HMA/LDAC-based regimens (with venetoclax), use of targeted therapies for molecular subgroups (e.g. IDH and FLT3), post-remission strategies, transplant consideration, and supportive care.