What are the strategies for patients who have relapsed?

What are the strategies for patients who have relapsed? I think relapses is, it depends a little bit on the setting and it depends on what therapy one has had before their relapse. I think we're fortunate, so first with some of the targeted therapies for example, we're fortunate for example in the field of FLIT3, so about a third of AML patients will have a FLIT3 mutation and we currently have two targeted therapies that are different and most of the time patients in the frontline setting, so during their 7 plus 3 induction will get the drug Mitastorin, but if they subsequently relapse there's actually a different drug called Giltaretinib that is approved for patients that have relapsed with a FLIT3 mutation with AML and then similarly a lot of times patients with IDH1 and IDH2 mutations, those are other gene mutations that are targetable and they end up being somewhere between 15 and 20 percent of all AML patients. Oftentimes patients will not receive one of those targeted therapies during their frontline treatment because they're currently not approved as part of frontline treatment. As of May 2022, targeted therapy for IDH1 mutations is approved for frontline treatment. The following still applies for IDH2 targeted therapy. And so oftentimes we won't use them until someone has relapsed because primarily because that's what their FDA approved use is for relapsed refractory AML with either an IDH1 mutation and that's the drug Ivasidinib or Tivsovo or with an IDH2 mutation and that's N-Asidinib or IDHYFA is the targeted therapy for IDH2. And then it becomes a real issue I think even more so with patients that don't have a targeted gene mutation or don't have a targetable gene mutation and I think one of the things when we think about when we approach a patient who has a relapsed AML is we're able to sort of give some risk stratification as to is this something that we're likely to be able to get back in remission or not. And a lot of it has to do with how long someone was in remission the first time. And so a patient that had a long, a couple of years of their first remission and they'd gotten in remission with an intensive chemotherapy regimen, we're very likely to be able to use another intensive chemotherapy regimen and get them back in remission. It's a lot more challenging for patients that have had a very short initial duration of remission on the order of months or the patient population that 20 to 40 percent of people that never get in remission with 7 plus 3 induction and there's a real question of what do you do for those people to try to get them back in remission is it, you know, one approach is sort of trying to hit harder and use more chemotherapy. And the other approach that I think is hopefully going to become something that's going to be a part of treatment for those patients that have an early relapse or have been refractory to their initial chemotherapy is using immunotherapies, so drugs that target the immune system to try to stimulate them to fight the leukemia.