Changing Landscape in Chronic Lymphocytic Leukemia Demands Specialty Pharmacy’s Attention

Chronic lymphocytic leukemia (CLL) is the most common leukemia in Western nations, and investigators have made great strides in clarifying the epidemiology, pathophysiology, and diagnostic criteria.  At the Asembia Specialty Pharmacy Summit 2019, a session reviewing this cancer revealed how quickly the landscape is changing.

Participants learned more about this important issue from Kirollos S. Hanna, PharmD, BCPS, BCOP, and Victoria T. Brown, PharmD, BCOP. The topic is particularly relevant because of the many frontline treatment options available for CLL that are distributed through restricted access. Specialty pharmacists who are involved with oncology teams that treat these patients learned about chromosomal abnormalities and deletions and the importance of the patient’s age, health, insurance benefits, and potential to tolerate adverse effects.

Hanna covered the 2019 National Comprehensive Cancer Network Guidelines for CLL, with options that include monotherapy and dual therapy in patients who do not have specific mutations. Traditional alkylating agents (eg, chlorambucil) have been used in combination with monoclonal antibodies or purine analogues, but this treatment paradigm is evolving toward new combinations with oral therapies with monoclonal antibodies. For patients who have the type of CLL associated with deletion (17p)/TP53, ibrutinib is preferred.

Many if not most of these patients will experience relapse or eventually develop refractory CLL. Here, too, available regimens include either monotherapy or combination approaches. Hanna said that the move toward targeted regimens is welcome and considerably more effective than the shotgun approach used previously.

Hanna addressed the need for pharmacists who care for patients who take ibrutinib to understand the potential adverse effects (AEs): hemorrhage, infection, cytopenia, cardiac rhythm, hypertension, secondary primary malignancies, tumor lysis syndrome, and embryo-fetal toxicity. Although these AEs are similar to those of many other antineoplastics, they cannot be ignored.

He also covered the off-label use of acalabrutinib, sharing that data indicate it may be effective in patients with CLL. Clinicians tend to use this off-label in the relapse or refractory CLL setting. Duvelisib also shows evolving data in patients with CLL.

Brown further emphasized points important to pharmacists. Clinical and specialty pharmacists who work on oncology teams will need to advise health care professionals about AEs associated with mono- or combination therapy, she said, and may be the team members most familiar with guideline recommendations. Because combined intravenous and oral regimens are often indicated in CLL, coordination of clinical care is paramount.

Defects can reduce medication adherence, and with cancer, adherence can make the difference between cure and treatment failure, Brown said. Pharmacists should not be under the misperception that because patients have serious life-threatening diseases, they will adhere to medication. Many patients need tremendous support so that they will complete the appropriate course of therapy. 

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