Brown Bag Consult®: Chronic Lymphocytic Leukemia

Patients who recieve a diagnosis of chronic lymphocytic leukemia (CLL) should not be overlooked in any pharmacy setting. Many of these patients are in dire need of support, encouragement, and care coordination. They will endure a grueling process of coping with diagnosis, treatment, and, in cases of recovery, the fear of recurrence. All these stages will impact the patient emotionally and physically.

As the most accessible member of the health care team, the pharmacist can provide the information and support patients with cancer need to get through what might be the most challenging period of their lives. Pharmacists’ willingness to help at this crucial time demonstrates a caring and concern that patients will likely never forget.

The Patient

Originally, EM came into the pharmacy complaining of extreme fatigue. At the time, the pharmacist on duty told EM to follow-up with his primary care provider for an evaluation because the fatigue was out of the ordinary and not due to any lifestyle change.

During their conversation, the pharmacist also noticed EM seemed to have lost a lot of weight, yet his abdomen looked enlarged compared with the rest of his body. Upon evaluation with his primary care provider, EM had laboratory work done, with the results showing EM had an enlarged spleen; this led to him receiving a diagnosis of active CLL.

During the evaluation, EM admitted to having awful night sweats and fevers. He was tested repeatedly for COVID-19, thinking he may have been infected. When his tests came back negative, he resorted to trying to ignore his symptoms before ultimately receiving the CLL diagnosis.

Case

EM is a 68-year-old man who has CLL and frequents your health care system. CLL has been a burden in addition to his multiple comorbidities. EM continuously struggles to understand CLL treatment options and is concerned about what this cancer means for his overall quality of life.

None of EM’s family members have had cancer or blood disorders, so receiving a CLL diagnosis threw an unexpected curve ball into his life. A retired salesman, EM has a limited support system because he is divorced and his adult children live out of state. To manage this disease, EM relies on his pharmacy team and other members of the hematology clinic.

Brown Bag Consult

Today, EM returns for follow-up after completing chemotherapy, and he is asking you to refill some of his monthly medications. As the 2 of you talk, he complains of worsening back pain to the point where he cannot stand up straight or walk well. He also mentions he feels short of breath and is still very fatigued.

When looking at the laboratory values on the paperwork EM has handed you, you see he has normal liver and renal function but his platelets and white blood cell counts are off. You explain to him that the immune system of individuals with CLL may not work efficiently because it may be making abnormal antibodies against its own red blood cells and/or platelets. These antibodies may then destroy the red blood cells, causing anemia or low numbers of platelets.

Antibodies that attack the body’s own red blood cells are called autoantibodies, and individuals with CLL can develop these autoantibodies at any time. However, the development of these autoantibodies is not necessarily related to the severity of the CLL. You stress to EM not to panic over the numbers and offer to help him arrange a follow-up with his hematologist to get further clarity over their meaning.

EM explains to you that he often wonders why he is not feeling better, is stressed over needing more tests and treatments, and doesn’t understand the different type of leukemias. He also explains that he often feels anxious about his future and has a hard time going to sleep and getting up in the morning.

After listening to EM, you encourage him to share these thoughts and feelings with his immediate care team so they can better support his needs holistically. Based on what he has explained, it seems possible EM is clinically depressed.

In this situation, as the pharmacist, you are not a primary decision maker on the care team. However, you can see many nonpharmacological ways that you can help EM, and you can make recommendations to his health care providers based on your observations.

It is also important to remember you are EM’s most accessible resource. For this reason, you set aside some time to talk to EM and explain the different types of CLL treatments available. After finding out that he’s not up-to-date on his immunizations, you encourage him to get those updated and you review with him the benefits of stopping smoking. EM tells you he appreciates your patience and how you talk things through with him in ways he can understand.

You also review EM’s “as needed” medications and realize he is overusing his prescribed anxiety, sleep, and pain medications. Upon noticing this, you offer to follow-up with EM’s care team, address the issues, and get him on a plan that can help have more lasting effects.

EM also explains he is not drinking water, which means he has been frequently dehydrated. In addition, he is not eating a balanced diet or getting any exercise.

After hearing this, you observe that, despite his weight loss due to the CLL, his most recent lipid panel is out of range, so you take his blood pressure and notice it is significantly elevated. EM does have documented dyslipidemia and hypertension, and he admits he no longer takes the medications for the chronic conditions. You express concern for his cardiac health and suggest he follow-up with his care team and get back on his prescribed medications after evaluation.

Regarding exercise, you talk about a support group that EM’s son recommended he seek out in his community because the group has a walking club. This type of regular activity may be beneficial, so you tell EM that once his pain is more managed, it may be easier for him to move around and perform his daily activities. This ease in movement could also help with his fatigue and mood.

Lastly, you note how important EM’s bone health and deep vein thrombosis prevention are and encourage him to join the walking club. These small efforts may seem minimal, but you mention that they all help aid his fight against the disease and support improvements in his quality of life.

About The Author

Jill Drury, PharmD, BCOP, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.