Navitoclax, Venetoclax, and Decitabine for the Treatment of Relapsed or Refractory Acute Myeloid Leukemia Previously Treated With Venetoclax

Inclusion Criteria:

Documented informed consent of the participant and/or legally authorized representative
For participants under the age of 18 years, documentation of adolescent assent by the participant and consent of both parents or guardian
Adults aged >= 18 years
Adolescent patients aged >= 16 years and < 18 years weighing at least 45 kg who have no other standard-of-care option for treatment
Eastern Cooperative Oncology Group (ECOG) =< 2

Patients with histologically confirmed AML, according to World Health Organization (WHO) criteria, with refractory/relapsed (R/R) disease following a venetoclax-containing regimen who are ineligible for therapies known to be effective for treatment of their AML.

Patients with extramedullary disease may be included if they also have marrow involvement
Patients with acute promyelocytic leukemia (APL) will not be eligible
Fully recovered from the acute toxic effects (except alopecia) to =< grade 1 of prior anti-cancer therapy
Ability to swallow pills

Absolute neutrophil count (ANC) >= 750/mm^3 (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)

NOTE: Growth factor is not permitted within 14 days of ANC assessment unless cytopenia is secondary to disease involvement
White blood cell (WBC) =< 25 x 10^9/L prior to initiation of study therapy. Cytoreduction with hydroxyurea prior to treatment and/or during cycle 1 may be required (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)

Platelets >= 75,000/mm^3

NOTE: Platelet transfusions are not permitted within 14 days of platelet assessment unless cytopenia is secondary to disease involvement
Total bilirubin =< 1.5 X upper limit of normal (ULN) (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)
Aspartate aminotransferase (AST) =< 3.0 x ULN (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)
Alanine aminotransferase (ALT) =< 3.0 x ULN (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)
Creatinine clearance of >= 45 ml/min per 24-hour urine test or the Cockcroft-Gault formula (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)
If in the absence of anticoagulants: International normalized ratio (INR) OR prothrombin (PT) =< 1.5 x ULN (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)
If in the absence of anticoagulants: Activated partial thromboplastin time (aPTT) =< 1.5 x ULN (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)

Left ventricular ejection fraction (LVEF) >= 50%

Note: To be performed within 28 days prior to day 1 of protocol therapy

Corrected QT interval (QTc) =< 480 ms

Note: To be performed within 28 days prior to day 1 of protocol therapy

Seronegative for human immunodeficiency virus (HIV) antigen (Ag)/antibody (Ab) combo, hepatitis C virus (HCV), active hepatitis B virus (HBV) (surface antigen negative), and syphilis (RPR) (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)

If positive, Hepatitis C RNA quantitation must be performed

Meets other institutional and federal requirements for infectious disease titer requirements

Note Infectious disease testing to be performed within 28 days prior to day 1 of protocol therapy
Women of child-bearing potential (WOCBP): negative urine or serum pregnancy test. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required (performed within 14 days prior to day 1 of protocol therapy unless otherwise stated)

Agreement by females and males of childbearing potential to use an effective method of birth control or abstain from heterosexual activity for the course of the study through at least 3 months (males) and 6 months (females) after the last dose of protocol therapy

Childbearing potential defined as not being surgically sterilized (men and women) or have not been free from menses for > 1 year (women only)

Exclusion Criteria:

Hematopoietic stem cell transplant within 100 days prior to day 1 of protocol therapy

Chemotherapy, radiation therapy, biological therapy, or immunotherapy within 14 days or 5 half-lives, whichever is shorter, prior to day 1 of protocol therapy with the following exceptions:

Subjects will be allowed to have been on venetoclax at screening and remain on it through treatment start.
Hydroxyurea is allowed prior to treatment and through cycle 1 for control of rapidly progressing leukemia
Strong or moderate CYP3A4 inducers within 14 days prior to day 1 of protocol therapy
Grapefruit, grapefruit products, Seville oranges (including marmalade containing Seville oranges) or star fruit consumed within 3 days prior to the first dose of study drug
Immunosuppressants (steroids =< 10 mg/day of oral prednisone or equivalent is allowed) within the last 28 days
Hematopoietic growth factors in the last 14 days
Must not have received or planning to receive live vaccine while being on study or 4 weeks before and after completion of treatment
Herbal medications known to affect platelet function within 14 days of therapy initiation
History of allergic reactions attributed to compounds of similar chemical or biologic composition to study agent
Active graft-versus-host-disease (GVHD)
Active central nervous system (CNS) disease
No measurable disease in the bone marrow
Active diarrhea
Gastrointestinal disorder that interferes with oral drug absorption such as malabsorption syndrome
Clinically significant cardiac morbidities (class III/IV cardiovascular disability according to the New York Heart Association classification, arrhythmia not stable on medical management, acute cardiovascular ischemic event within 6 months of enrollment, etc.)
Clinically significant uncontrolled illness
Active infection requiring antibiotics
Active/uncontrolled HIV infection, acquired immunodeficiency syndrome (AIDS), or currently taking contraindicated medications for HIV control
Diagnosis of Gilbert's disease
Any other active malignancy at time of enrollment. Exceptions include basal/squamous cell carcinoma, in situ adequately treated breast and uterine cancer
Females only: Pregnant or breastfeeding
Any other condition that would, in the Investigator's judgment, contraindicate the patient's participation in the clinical study due to safety concerns with clinical study procedures
Prospective participants who, in the opinion of the investigator, may not be able to comply with all study procedures (including compliance issues related to feasibility/logistics)