Tomivosertib With Azacitide and Venetoclax for the Treatment of Patients With Newly Diagnosed Acute Myeloid Leukemia Who Are Not Suitable for Intensive Chemotherapy

Inclusion Criteria:

Patients age >= 18 years

Patients with newly diagnosed previously untreated AML (based on the International Consensus Classification of Myeloid Neoplasms and Acute Leukemias) who are not suitable for intensive chemotherapy based on one or more of the following three criteria:

Age >= 75 years
Eastern Cooperative Oncology Group (ECOG) performance status of 2 or 3

One or more of the following comorbidities:

Severe cardiac comorbidity (including congestive heart failure requiring treatment, ejection =< 50%, chronic stable angina, prior anthracycline exposure with increased risk for cardiomyopathy)
Pulmonary comorbidity (including diffusion capacity of the lung for carbon monoxide [DLCO] =< 65% or forced expiratory volume in 1 second [FEV1] =< 65%)
Moderate hepatic impairment with total bilirubin > 1.5 to 3 times the upper limit of normal
Estimated glomerular filtration rate (eGFR) >= 30 mL/min/1.73 m^2 to < 45 mL/min/1.73 m^2 (estimation based on Modification of Diet in Renal Disease (MDRD) formula, by local laboratory)
Any other comorbidity or molecular/cytogenetic subtype of AML (to be documented in the electronic medical record [EMR]) that the physician judges would not benefit from intensive chemotherapy; the comorbidity and molecular/cytogenetic subtype of AML must be reviewed and approved by the lead principal investigator before study enrollment NOTE regarding prior treatment for AML: For disease control during screening and before the start of cycle 1 day 1 (C1D1), per institutional practice, patients may receive steroids, hydroxyurea or leukapheresis to control white blood cell (WBC). Patients may have received prior hypomethylating agent and/or venetoclax and/or investigational treatment for antecedent myeloid neoplasm. Hydroxyurea may be given during screening and cycle 1 to control WBC
For patients with a known history of human immunodeficiency virus (HIV), infected patients on effective anti-retroviral therapy must have a viral load undetectable for 6 months prior to registration
For patients with a known history of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated
Patients with a known history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load
Patients must agree to serial bone marrow aspirate/biopsies
The effects of venetoclax and tomivosertib on the developing human fetus are unknown. Azacitidine is classified by the Food and Drug Administration (FDA) as a pregnancy category D medication, indicating it may cause fetal harm when administered to a pregnant woman. For these reasons, patients of child-bearing potential (POCBP) must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) and refrain from donating eggs from the time of informed consent, for the duration of study treatment, and for 30 days following completion of study therapy. Should a patient become pregnant or suspect they are pregnant while they or their partner are participating in this study, they should inform their treating physician immediately. People with sperm-producing reproductive capacity treated or enrolled on this protocol must also agree to use adequate contraception (or abstinence or vasectomy) and refrain from donating sperm from the time of informed consent, for the duration of study therapy, and 30 days after completion of study therapy.

NOTE: A POCBP is any person with an egg-producing reproductive tract (regardless of sexual orientation, having undergone a tubal ligation, or remaining celibate by choice) who meets the following criteria:

Has not undergone a hysterectomy or bilateral oophorectomy

Has had menses at any time in the preceding 12 consecutive months (and therefore has not been naturally postmenopausal for > 12 months)

POCBP must have a negative serum beta-subunit of human chorionic gonadotropin (beta-hCG) pregnancy test (sensitivity of at least 25 mIU/mL) within 14 days prior to registration on study and have a negative serum beta-hCG pregnancy test (sensitivity of at least 25 mIU/mL) within 72 hours prior to the start of study treatment. NOTE: The screening serum pregnancy test can be used as the test prior to the start of study treatment if it is performed within the 72-hour timeframe
Patients must provide written, signed, and dated informed consent prior to study registration. Patient must have the ability to understand and the willingness to sign a written informed consent document. The patient must be willing and able to comply with the protocol for the duration of the study. NOTE: No study-specific screening procedures may be performed until written consent has been obtained

Exclusion Criteria:

Patients who are receiving any other investigational agents
Patients who have a prior or concurrent malignancy that may interfere with study treatment or safety. NOTE: Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen (i.e., cancers under observation that do not require treatment, resectable skin cancer, low risk prostate cancer, ductal carcinoma in situ [DCIS], lobular carcinoma in situ [LCIS], etc.) are eligible per lead primary investigator (PI) discretion. Patients with prior myelodysplastic syndrome (MDS) or myeloproliferative neoplasms (MPN) are eligible
Patients who have conditions that would interfere with drug absorption
Patients who have conditions that would interfere with their ability to swallow oral medications
Patients who have a history of allergic reactions attributed to compounds of similar chemical or biologic composition to tomivosertib, azacitidine, and/or venetoclax

Patients who have an uncontrolled intercurrent illness including, but not limited to any of the following, are not eligible:

Uncontrolled systemic infection (defined as ongoing signs/symptoms related to the infection without improvement despite appropriate antibiotics, antiviral therapy, antifungal therapy and/or other treatment)
Unstable angina pectoris
Cardiac ventricular arrhythmia, except for patients that can be successfully treated with rate control or anti-arrhythmic agents
Psychiatric illness/social situations that would limit compliance with study requirements
Any other illness or condition that the treating investigator feels would interfere with study compliance or would compromise the patient's safety or study endpoints
Patients who are pregnant or nursing. Pregnant people are excluded from this study because azacitidine is pregnancy category D per the FDA, with the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the pregnant person with azacitidine, breastfeeding should be discontinued if the person is treated with azacitidine
Patient must avoid consuming grapefruit, grapefruit products, Seville oranges (including marmalade containing Seville oranges), star fruit or St. John's Wort before the anticipated first dose of venetoclax and continue to not consume these agents while on treatment with ventoclax