Newly diagnosed acute myeloid leukemia in Fit patients: 2026 treatment algorithms.

The introduction of venetoclax (a BCL2 inhibitor) and targeted therapies, including inhibitors of CD33, FLT3, IDH1, IDH2, and menin, has expanded treatment options for newly diagnosed acute myeloid leukemia (AML). In younger, fit patients, the primary goal remains long-term survival, which in most cases is secured through allogeneic stem cell transplant. Transplant in first complete remission is recommended for FLT-ITD, TP53 mutated, KMT2A rearranged, AML with other adverse genetic abnormalities, and is considered in most intermediate-risk patients. It is also recommended in relapsed/refractory disease or persistent measurable residual disease (MRD). The role of intensive chemotherapy, such as cytarabine (7) plus anthracycline (3), is limited to patients with core-binding factor AML, NPM1 mutation, CEBPA bZIP mutation and those with intermediate-risk disease. Intensive regimens such as FLAG-IDA and CLIA plus venetoclax have shown impressive long-term outcomes, but their use is not widespread. In FLT3 mutated AML, 7 + 3 plus an FLT3 inhibitor (midostaurin or quizartinib) remains a standard, with venetoclax-hypomethylating agent-FLT3 inhibitor triplets emerging as an alternative. Similarly, in IDH1/2 mutated AML, venetoclax-hypomethylating agent with or without IDH1/2 inhibitor combinations challenge intensive chemotherapy approaches. Patients with TP53 mutations or other adverse-risk features, where intensive chemotherapy is known to be less effective, should be referred for clinical trials. There remains ongoing debate regarding optimal management of fit patients with newly diagnosed AML without targetable mutations, as emerging data suggest that venetoclax- hypomethylating agents may be comparable to intensive chemotherapy in selected patients proceeding to transplant. Accordingly, treatment decisions should be individualized to maximize remission while minimizing toxicity.