Treatments for CLL, SLL: What Pharmacists Should Know

In a session at Great Debates & Updates Oncology Pharmacy, Kirollos Hanna, PharmD, BCPS, BCOP, provides pharmacist-guided decisions that should be implemented for treatment selections among patients with chronic/small lymphocytic leukemia (CLL/SLL), and reviews strategies for managing polypharmacy and related adverse events.  

According to Dr Hanna, CLL/SLL are the “most common form of adult leukemia in Western countries.” He reported that in 2021, there have been 21,250 new cases and 4320 deaths reported. These instances have been among patients with a median age of 70 years old at diagnosis and median age of 81 years old at death. Further, these cases made up 1.1% of new cancer cases across the US. Over 2011-2017, death rates fell on an average of 2.9% each year, Dr Hanna reported, totaling a 5-year overall survival of 87.2%.  

Dr Hanna explained that the initial changing treatment paradigm in CLL was to prolong progression free survival among patients while they were on therapy. He explained that use of chemoimmunotherapy is disease eradication, and the goal of BCR inhibitors is disease control. He then explained that the new treatment paradigm includes a time-limited, novel, agent-only therapy for CLL. More specifically, BCR inhibitors are used for disease control, and BCL2 inhibitors are used for disease eradication. Finally, Dr Hanna highlighted factors to consider in an alternative treatment paradigm in CLL. These factors included the following for BTK inhibitors (BTKi) and venetoclax plus obinutuzumab: 

• Convenience;
• Long-term efficacy data;
• Multiple phase 3 data;
• Data for efficacy of venetoclax at time of ibrutinib progression;
• Prolong PFS while on therapy;
• Potential for 1-year time-limited therapy;
• No known cardiac or bleeding risks;
• Less concern with long-term adherence;
• Potential for cost-savings if 1 year of therapy is durable; and
• Prolongs PFS after MRD negative. 

For patients with CLL/SLL, pharmacists and providers should be prepared to address and manage adverse events.  

According to Dr Hanna, patients “receiving BTKi should be counseled and monitored for bleeding and cardiac-related events and should consider referral to a cardio-oncologist.” 

Additionally, although venetoclax was linked to a favorable risk-benefit profile, Dr Hanna said patient profiling is required to mitigate the risk of tumor lysis syndrome.

Finally, pharmacists should be aware of concomitant medication monitoring with oral oncolytics among this patient population.