LLM 2021 | Treatment sequencing options for recurrent CLL
Michael Choi, MD, UC San Diego Health, San Diego, CA, discusses treatment options for patients with recurrent chronic lymphocytic leukemia (CLL). Patients who have severe side effects or have progressed from current BTK inhibitors can be treated with alternative BTK inhibitors such as acalabrutinib, which has fewer side effects and the same efficacy as ibrutinib, or non-covalent BTK inhibitors such as pirtobrutinib. Venetoclax, chimeric antigen receptor (CAR) T-cell therapy, and allogeneic stem cell transplant are additional treatments to be considered for patients who have progressed from existing therapies. This interview took place at the Lymphoma, Leukemia & Myeloma Congress 2021.
Transcript (edited for clarity)
Yeah, certainly over the past few years, we’ve had the benefit of having many more treatment options for our patients with CLL. It is certainly a great thing to have for our patients who have side effects and requests to change therapies for that reason or unfortunately have disease progression on a therapy. I guess I think the main things that I take into account when I’m discussing new treatment, or next treatments, for a patient are really those things, why they’re switching, and if they’re switching, then, for side effects, then we can often consider drugs of the same class for patients on BTK inhibitors...
Yeah, certainly over the past few years, we’ve had the benefit of having many more treatment options for our patients with CLL. It is certainly a great thing to have for our patients who have side effects and requests to change therapies for that reason or unfortunately have disease progression on a therapy. I guess I think the main things that I take into account when I’m discussing new treatment, or next treatments, for a patient are really those things, why they’re switching, and if they’re switching, then, for side effects, then we can often consider drugs of the same class for patients on BTK inhibitors. We now have a few different BTK Inhibitor options, and now published data from a trial that directly compared acalabrutinib with ibrutinib, where the incidents of cardiovascular side effects, mainly hypertension and arrhythmia, were lower with acalabrutinib. So, especially for patients switching therapy for that reason, or for those concerns, switching from ibrutinib to acalabrutinib is an option.
It doesn’t appear that there’s a change in efficacy between those agents and, certainly based on their having this similar mechanism action, patients progressing on one BTK inhibitor probably shouldn’t switch to another covalent BTK inhibitor.
I did discuss this with others at this meeting that there’s emerging and growing data with the non-covalent BTK inhibitors pirtobrutinib, the [inaudible] drug and others. So it will be good to see more data from further trials with these, and I think it’ll be great that these will be options for our patients, as well.
Certainly, venetoclax is an effective drug for this setting. When I look back on published reports of patients progressing in ibrutinib from 2015, the prognosis were dismal. Patients were only living a few months. So that’s already much better now. I think venetoclax is a large part of that improvement. We are unfortunately starting to see a few patients that are progressing on venetoclax, as well. Certainly, patients that haven’t had a BTK inhibitor before will have a good chance of getting back into remission with that. And I think in that setting is where we need to keep innovating and consider some other things like CAR T-cells or allogeneic stem cell transfer, for patients that get back into remission.
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Disclosures
Clinical trial research support from PCYC and Abbvie.
