Specialty Pharmacists Have Broad Responsibilities in Chronic Lymphocytic Leukemia

AT JUST 1.2%, chronic lymphocytic leukemia (CLL) represents a small percentage of all new cancer cases but is the most common leukemia in Western countries. In 2019, oncologists diagnosed an estimated 20,720 new cases and approximately 3930 people died. One virtual symposium held in conjunction with the Asembia Specialty Pharmacy Summit explored this cancer, which most often occurs in older adults.

Alison Duffy, PharmD, BCOP, presented a comprehensive overview. Patients with CLL experience a gradual, malignant accumulation of lymphocytic blood cells that begins in the bone marrow and eventually extends to the blood. Genomic alterations cause leukemic transformation that inhibits apoptosis of clonal B cells. Del(17p) is the most important prognostic factor, reflecting the loss of a key tumor suppressor gene.

Oncologists generally begin treatment when patients’ end organ function is threatened, or they have progressive bulky disease, extensive adenopathy, or splenomegaly. Other factors that may signal a need for treatment are progressive bone marrow failure, constitutional symptoms, autoimmune anemia, leukostasis, or increasing absolute lymphocyte count. Those who are at least 65 years of age or who are younger and frail are treated in a “go slow” manner, whereas patients who are younger than 65 years with no significant comorbidities can be treated more aggressively.

Duffy discussed the evolving treatment paradigm of CLL, underscoring that therapy selection and patient management are complex. She focused on the small-molecule oral agents, including acalabrutinib, duvelisib, ibrutinib, idelalisib, and venetoclax, as well as evidence for their use in combination strategies. She demonstrated how each affects pathogenic pathways in CLL and also differentiated between treatment algorithms for naïve CLL and relapsed/refractory CLL. Ibrutinib and venetoclax are both approved as single agents in the first line, but other first-line therapies are combinations of acalabrutinib with obinutuzumab and venetoclax with obinutuzumab.

Duffy finished her presentation by discussing novel therapies currently in clinical trials and future implications. A number of other agents, both smallmolecules and monoclonal antibodies, are currently in clinical trials either alone or in combination with existing drugs.

Kirollos S. Hanna, PharmD, BCPS, BCOP, emphasized multidisciplinary collaboration with the fact that pharmacy-led chemotherapy management programs can improve 5 aspects of care:

• Patient knowledge
• Patient adherence to therapy and clinician adherence to prescribing standards
• Time to medication access
• Identification of clinically significant issues
• Provider and patient satisfaction

Hanna indicated that common standards of care exist for infection prophylaxis. He shared prophylactic recommendations for Pneumocystis jirovecii pneumonia, herpes simplex virus, cytomegalovirus, and hepatitis B related to use of specific agents.

Specialty pharmacists need to be closely involved with management of adverse effects (AEs). Hanna noted that AEs are the most common reason for kinase inhibitor discontinuation. He reviewed each agent’s most common AEs and suggested clinical interventions.

Hanna emphasized the importance of a medically integrated model. He discussed the 3 stages of treatment: (1) initiation, (2) coordination, and (3) maintenance, indicating that certain actions are “operational best practices.” A patient education checklist that he presented emphasized all of these points.

Finally, he highlighted the consequences of failure to access these costly agents. Prescription abandonment, poor adherence, treatment delay, decreased quality of life, and suboptimal disease outcomes are problematic for patients. He urged pharmacists to investigate benefits early in the process, have patients engage with assistance teams and counselors, look at every available co-pay assistance program, explore free drug programs, and integrate the financial team into the multidisciplinary process.