Venetoclax with azacitidine disrupts energy metabolism and targets leukemia stem cells in patients with acute myeloid leukemia

Nat Med. 2018 Dec;24(12):1859-1866. doi: 10.1038/s41591-018-0233-1. Epub 2018 Nov 12.


Acute myeloid leukemia (AML) is the most common acute leukemia in adults. Leukemia stem cells (LSCs) drive the initiation and perpetuation of AML, are quantifiably associated with worse clinical outcomes, and often persist after conventional chemotherapy resulting in relapse1-5. In this report, we show that treatment of older patients with AML with the B cell lymphoma 2 (BCL-2) inhibitor venetoclax in combination with azacitidine results in deep and durable remissions and is superior to conventional treatments. We hypothesized that these promising clinical results were due to targeting LSCs. Analysis of LSCs from patients undergoing treatment with venetoclax + azacitidine showed disruption of the tricarboxylic acid (TCA) cycle manifested by decreased α-ketoglutarate and increased succinate levels, suggesting inhibition of electron transport chain complex II. In vitro modeling confirmed inhibition of complex II via reduced glutathionylation of succinate dehydrogenase. These metabolic perturbations suppress oxidative phosphorylation (OXPHOS), which efficiently and selectively targets LSCs. Our findings show for the first time that a therapeutic intervention can eradicate LSCs in patients with AML by disrupting the metabolic machinery driving energy metabolism, resulting in promising clinical activity in a patient population with historically poor outcomes.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Apoptosis / drug effects
  • Azacitidine / administration & dosage*
  • Bridged Bicyclo Compounds, Heterocyclic / administration & dosage*
  • Electron Transport Complex II / drug effects
  • Energy Metabolism / drug effects
  • Female
  • Humans
  • Ketoglutaric Acids / metabolism
  • Leukemia, Myeloid, Acute / drug therapy*
  • Leukemia, Myeloid, Acute / genetics
  • Leukemia, Myeloid, Acute / pathology
  • Male
  • Neoplastic Stem Cells / drug effects*
  • Neoplastic Stem Cells / pathology
  • Oxidative Phosphorylation / drug effects
  • Proto-Oncogene Proteins c-bcl-2 / antagonists & inhibitors
  • Proto-Oncogene Proteins c-bcl-2 / genetics
  • Succinate Dehydrogenase / genetics
  • Sulfonamides / administration & dosage*
  • Tricarboxylic Acids / metabolism


  • BCL2 protein, human
  • Bridged Bicyclo Compounds, Heterocyclic
  • Ketoglutaric Acids
  • Proto-Oncogene Proteins c-bcl-2
  • Sulfonamides
  • Tricarboxylic Acids
  • Electron Transport Complex II
  • Succinate Dehydrogenase
  • Azacitidine
  • venetoclax