Experts Discuss Treatment Considerations for Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is a cancer of the blood and bone marrow that can be treated to extend the life of some patients by decades. Treatments and best practices are developing rapidly, and health care providers need to stay up to date on all relevant information. In a Pharmacy Times Insights video series, a panel of experts discussed how to best treat and monitor patients living with CLL.

The panel featured Alison Duffy, PharmD, BCOP, an associate professor and clinical pharmacy specialist in oncology at the University of Maryland School of Pharmacy, and Cody Steeves, PharmD, BCOP, a clinical pharmacist for Biologics by McKesson.

CLL is often treated with Bruton tyrosine kinase (BTK) inhibitors. Several toxicities are associated with BTK inhibitors, such as cardiovascular disease, skin dryness and diarrhea. A pharmacist can help to mitigate and monitor these toxicities, especially when used for long-term treatment.

“I think there's a huge role for so many different types of pharmacists in the clinic setting, where I am, at the specialty pharmacy, where you are, and everywhere in between. We have data to show that patients who are taking ibrutinib or another agent we haven't talked about that can be used in the relapsed/refractory setting, idelalisib, we know that the first 4 months are really important for detecting. That's where patients develop those toxicities leading to nonadherence” Duffy said. “So I think it's critical to educate patients up front about the toxicities and also follow patients closely, within the first 2 weeks and then monthly, every 3 months or so, specifically for toxicities, I think that's important, but of course, also for adherence and making sure access is there.”

For some newly diagnosed patients with CLL, BTK inhibitors will be their sole therapy. The RESONATE and RESONATE-2 trial examined the efficacy and best uses for BTK inhibitors.

“I think it's really exciting to see some of that data being even more confirmatory in the relapsed/refractory setting for ibrutinib. In the upfront setting, or newly diagnosed setting, the RESONATE-2 trial with ibrutinib also establishing ibrutinib as the first-line choice for patients that were older and those patients without deletion of 17P, showing us that significantly longer progression-free survival benefit seen across all those high-risk subgroups, such as those with deletion of 17P,” Duffy said.

The criteria for front-line therapy decision-making are changing as well. A number of facts, such as whether a person is elderly and their mutation status, can determine which therapies are used.

“I think the criteria used to be far more rigid in terms of patients that were frail or unfit, those that were older, maybe younger with comorbidities, and those that were young and fit. Previously, if you're familiar with the guidelines, those that are listening in, there used to be very stringent buckets such as no-go, slow-go, and go-go. So historically, we've had these stringent boxes. I think there's a number of factors still to consider, and it is a very patient-centric shared decision,” Duffy said. “Some of the things that I would think about would be age, fitness, comorbidities such as atrial fibrillation, and renal function if we're going to give something like fludarabine within the FCR regimen. Cytogenetics might be important, but mutation status can be really helpful, as well.”

Although specialty pharmacists are not involved in the first-line therapy decision-making process, they do understand the changes in guidelines and routine. For example, according to Steeves, acalabrutinib has become a lot more common; however, ibrutinib is still widely used and is the oldest treatment used in a first-line setting.

“I think old habits die hard. Doctors are still using it. They're still getting great efficacy out of it, so why stop? When something is working well for you, why ruin a good thing? We definitely see that. We see venetoclax, and we don't dispense the [intravenous] therapy, but we do speak with our patients if they're receiving a combination, and many of them are, we keep an eye on them for that,” Steeves said. “But we do tend to see those 3 oral agents as our primary first-line therapies for treatment-naïve patients these days, as well as switching back and forth to the other ones, if and when they become refractory or intolerable, and anything in between, in that setting as well.”