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Treosulfan is a small molecule, DNA alkylating agent used primarily as part of a myeloablative conditioning regimen prior to allogeneic hematopoietic stem cell transplantation (alloHSCT) in adults and pediatric patients aged 1 year and older with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). It acts as a prodrug that is converted under physiological conditions into active epoxide metabolites, which alkylate DNA, leading to cross-linking within the DNA molecule. This results in cytotoxicity by preventing cell division and inducing cell death. Treosulfan exhibits immunosuppressive effects by depleting hematopoietic stem cells and reducing cellularity of lymphatic organs. It was approved by the EMA in June 2019 and by the FDA in January 2025 for use in combination with fludarabine[1][3][4][7].
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