Report of 4 cases monitored at the do Servidor Publico Estadual Hospital (IAMSPE), SP. Patients considered unfit for 3+7 regimen received AZAVIT-ABCEF (azacytidine, filgrastim, erythropoietin combined with high doses of vitamins B1, C, and D3). In cases of relapse, they were treated with azacytidine 75 mg/m2 and venetoclax 400 mg for 7 days every 28 days (aza + veneto).

Data collection from the IAMSPE digital system.

Patient 1: Female, 77 years old, AML diagnosed in Oct/21. Hemogram: blasts=36%, Bone Marrow: blasts = 78%, Immunophenotype (IFT): CD13, CD15, CD33, CD34, CD71, CD117, CD123, HLA-DR. FISH: KMT2 gene trisomy in 45/200 metaphases; Karyotype: 47, XX, +11[3] /46, XX[17]. Received AZAVIT-ABCDEF for 15 months without transfusion need until worsened hemogram in Jan/23; Bone Marrow: blasts = 56%. Started aza + veneto in Feb/23, after 1 cycle, bone marrow: 3% immature cells and monocytosis of 13%. Sustained pancytopenia requiring blood component support for 55 days. Cycle 2 delayed, currently on 6th cycle, Hemogram JUL/2023: Hb = 13.8 g/dL, WBC = 6030/mm3 (62.1,70.0,2.32.4,1), Platelets = 317000. Patient 2: Female, 71 years old, AML diagnosed in Jan/22. Hemogram: monocytosis = 55%, Bone Marrow: blasts = 94%, IFT: CD13, CD14, CD15, CD33 CD36, CD56, CD64, HLA-DR, MPO. FISH and Karyotype: normal. Received AZAVIT-ABCDEF for 11 months without transfusion need until worsened hemogram monocytes = 58%, Bone Marrow: blasts = 67%. Started aza + veneto in Jan/23, currently on 7th cycle. Current Hemogram: Hb = 14.5 g/dL. WBC = 3000 (2/42/1/0/39/16), Platelets = 204. Patient 3: Female, 69 years old, AML diagnosed in May/22. Hemogram: bicytopenia, Bone Marrow: blasts = 79%, IFT: CD4, partial CD11b, partial CD13, CD15, CD33, CD36, CD38, CD64, CD56, CD123, HLA-DR, MPO. FISH and Karyotype: normal. Received AZAVIT-ABCDEF for 8 months without transfusion need until worsened hemogram in Jan/23; Bone Marrow: blasts = 35%. Started aza + veneto in Feb/23, after 1 cycle, patient developed pancytopenia and marrow showed maturation arrest. Patient had cycles postponed, completed 3 cycles with sporadic blood component need. JUL/23: Hb = 7.6 g/dL. WBC = 4020 (1/1/3/38/0/0/52/5), Platelets = 34000. Patient 4: Female, 58 years old, AML diagnosed in Oct/22. Hemogram: blasts = 6%, Bone Marrow: blasts = 21%, IFT: CD13, CD33, CD34, CD38, CD117, CD123, HLA-DR, MPO. FISH and Karyotype: normal. Received AZAVIT-ABCDEF for 8 months without transfusion need until worsened hemogram in Jun/23; Bone Marrow: blasts = 35%. Started aza + veneto in Jun/23, after 1 cycle, achieved remission; in the second cycle, patient developed prolonged pancytopenia and awaits marrow recovery.

AZAVIT-ABCDEF protocol potentially enhances mitochondrial metabolism and discourages anaerobic metabolism, inducing leukemic cells to enter the Krebs cycle and promoting differentiation. Using venetoclax during relapse possibly exploited leukemic cells’ sensitivity to mitochondrial blockade with anti-BCL2, explaining the positive response in all 4 patients.

The patients demonstrated an improved quality of life with increased overall survival. In this pathology where the diagnosis is practically a death sentence for individuals in this age group or with comorbidities, the results are promising.