This is an excellent question and it comes up often in our practice. Our practice has been to continue midostaurin as maintenance. This is in line with the Phase III RATIFY trial where they gave midostaurin 50 mg orally twice daily, for twelve 28-day cycles (1 year of continuous maintenance). Since you started with midostaurin, if the patient is tolerating it we would just continue it. This all said, I agree with you that NCCN has made things confusing where they only make a recommendation for quizartinib in patients who cannot receive transplant. In the QUANTUM-FIRST trial the investigators performed a subgroup analysis of patients who did not receive transplant and found an Overall survival benefit in the quizartinib arm compared with placebo. This did not reach statistical significance however. This analysis is in the supplement on page 12 figure S2. That all said, in RATIFY, when this same subgroup is looked at, midostaurin also improved OS in patients who did not receive transplant (also not statistically significant). Page 20 Figure S3B of RATIFY supplement. Both of these are post-hoc, subgroup analyses that were underpowered. So I can't say I feel more strongly that one should be given versus the other. Ideally quizaritinib should have compared itself to midostaurin for us clinicians to know what to do. Given the additional AE profile of quizaritinib and the logistics required for enrolling into the REMS program and the fact we have similar results between the two studies and we don't know which one is better than the other, we typically just use midostaurin. We consider both approaches appropriate but tend to just continue midostaurin. We NEVER use oral azacitidine maintenance. This is for a variety of reasons outlined in a podcast: https://open.spotify.com/episode/4a6pIF89LoRb2nR2tdkWpx