Experts Outline Best Practices in the Treatment of 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 even 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 included 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.

Both intravenous (IV) and oral CLL medications are available, each with their own benefits and disadvantages. A combination method is also used by many patients, but that also presents a unique set of challenges.

“Some of the economic challenges we've seen have been the timely approval of the oral and the IV therapy together because of pharmacy benefits and medical benefits, and so that can be a challenge, especially if a patient's disease is very aggressive. If they have progressed on ibrutinib it would be really important to start their subsequent therapy very quickly, or it can progress to Richter transformation,” Duffy said. “The economic challenges in improving can be a barrier. As pharmacists, anything we can do to facilitate the approval process, and in the clinic, I can certainly help with the prior authorization process.”

For a patient with CLL using oral medication, it’s extremely important for pharmacists to monitor their adherence closely. For example, pharmacists should be making sure treatment regimens are set up in such a way that patients take their medication at proper intervals and with food if needed.

“If a patient doesn't reliably eat every day at breakfast, I ask them, ‘Which meal do you eat the most reliably?’ Most people have at least 1. Take it with that meal, drink plenty of water, especially early on, it's very important with venetoclax. It's important with ibrutinib, too—important with all of them—staying well hydrated. Especially at the initiation of therapy as we're going to see white cells die a lot faster. We want to make sure we're flushing everything through there,” Steeves said.

Pharmacists should do their best to educate their patients on the importance of adherence, especially when it comes to oral medications. IV therapy is typically much easier for a physician to manage, according to the panel.

“As a pharmacist, it's really important to educate the patients on this adherence, starting with the first conversation. I think this is one of the hardest things for a doctor's office to manage. They can't watch a patient swallow a pill every day,” Steeves said. “If a patient has 6 cycles of chemotherapy, they either came or they didn't, so we know if they got their IV chemotherapy. But doctors can write a prescription for a 6-month supply of an oral agent and just hope and pray that the patient is going to take it every day, and hope that the pharmacy can manage that accordingly.”

For optimal success, health care providers should follow the literature on CLL closely.

The panel noted that when health care providers now see a patient with CLL, they can expect them to survive for years, maybe even decades, instead of just trying to control the disease for a few months.

“The data will tell us more as we move along with that. I think about long-term MRD [minimum residual disease] response rates, what they may mean, the efficacy of long-term drug-free intervals, and as we mentioned, the re-challenging versus switching to a new agent, what that's going to look like. We're going to have to have data on that. For CLL, the nature of the disease, it probably will come back. To think that we will cure the disease in most patients is pretty unlikely. These chronic diseases generally aren’t eliminated” Steeves said.