Post-transplant HMA maintenance (oral decitabine/cedazuridine)

Current understanding

Post-transplant relapse remains a leading cause of failure in myeloid neoplasms, motivating prospective evaluation of maintenance strategies. Oral decitabine/cedazuridine (ASTX727/Inqovi) is being tested as post-allogeneic-HCT maintenance in MDS and CMML to reduce relapse risk, leveraging an established hypomethylating agent in a novel maintenance context. Early-phase trial data are emerging; efficacy, tolerability, and applicability to MPN (including MF and MPN-AP/BP) remain open questions.

Evidence log

• 2026-07-16 — Study of Tagraxofusp for Post-Transplant Maintenance for Patients With CD 123+ AML, MDS, MF and CMML (HSCT 002): Cross-connection with tagraxofusp-post-transplant-maintenance: CD123-directed tagraxofusp joins HMA (and pegINFa, ven+HMA) as a mechanistically distinct candidate competing for the post-allo-HCT maintenance niche in myeloid neoplasms including MF and CMML. (novelty: 3)
• 2026-06-23 — A Pragmatic Clinical Trial to Prevent Relapse for Myeloid Malignancies With Measurable Disease Prior to Allogeneic Transplant: Pragmatic prospective trial uses MRD status to assign post-HCT maintenance in myeloid malignancies — HMA-based maintenance is one of the candidate arms, shifting HMA maintenance from a uniform strategy to an MRD-directed one. (novelty: 3)
• 2026-06-04 — AlloHCT With PegINFa for Myelofibrosis: cross-connection with post-transplant-peginfa-maintenance-mf: Both represent post-alloHCT maintenance strategies for MPN/MF; pegINFa (immunomodulatory) and oral decitabine/cedazuridine (hypomethylating) are mechanistically distinct candidates competing for the same post-transplant relapse-prevention niche. (novelty: 4)
• 2026-05-20 — Venetoclax Added to Fludarabine + Busulfan Prior to Transplant and to Maintenance Therapy for AML, MDS, and MDS/MPN: Phase I/II trial adds venetoclax to post-transplant HMA maintenance (azacitidine or oral decitabine/cedazuridine) in AML/MDS/CMML/MDS-MPN-U — tests a BCL2-inhibitor + HMA combination maintenance strategy beyond HMA monotherapy, with safety as the primary readout. (novelty: 3)
• 2026-05-15 — Chemotherapy (Decitabine in Combination With FLAG-Ida) and Total-Body Irradiation Followed by Donor Stem Cell Transplant for the Treatment of Adults With Myeloid Malignancies at High Risk of Relapse: cross-connection with decitabine-flagida-tbi-conditioning: Decitabine used inside the conditioning regimen here overlaps mechanistically with post-transplant oral decitabine/cedazuridine maintenance — raises sequencing/resistance questions when HMA exposure spans both peri-conditioning and maintenance. (novelty: 3)
• 2026-03-04 — Pacritinib With Standard of Care Azacitidine or Decitabine as a Bridge to Allogeneic Hematopoietic Stem Cell Transplant for Patients With Accelerated and Blast Phase Myeloproliferative Neoplasms: cross-connection with ap-bp-mpn-bridging: Pacritinib + HMA bridging in AP/BP-MPN raises questions about HMA sequencing, as the same agents (azacitidine/decitabine) are also used for post-transplant maintenance — potential resistance or cumulative toxicity considerations. (novelty: 3)
• 2026-03-30 — Inqovi Maintenance Therapy in Myeloid Neoplasms: cross-connection with post-transplant-relapse-ciml-nk: Complementary post-HCT strategies: HMA maintenance aims to prevent relapse, while CIML NK targets established relapse — together they bracket the post-transplant relapse-control toolkit. (novelty: 3)

Open questions

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