Oncology

Chronic Lymphocytic Leukemia

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Kinase Inhibitor Intolerance in Patients With Chronic Lymphocytic Leukemia

patient care perspectives by Anthony R. Mato, MD, MSCE

Overview

Owing to the epidemiology of chronic lymphocytic leukemia (CLL), age-associated comorbidities are commonly present at the time of CLL treatment initiation. As such, the distinct toxicity and tolerability profiles of the novel agents may be important to consider in view of an individual patient’s comorbidities. Novel agents for CLL include ibrutinib, a Bruton’s tyrosine kinase (BTK) inhibitor; idelalisib, a phosphatidylinositol 3-kinase (PI3K) inhibitor; and venetoclax, a B-cell lymphoma-2 (BCL-2) inhibitor. Here, Anthony Mato, MD, MSCE, relates several key points on kinase inhibitor intolerance and offers perspectives on adverse events that have been reported with each of the 3 novel agents.

Expert Commentary

Anthony R. Mato, MD, MSCE 

Director, Chronic Lymphocytic Leukemia Program Associate Attending, Memorial Sloan Kettering Cancer Center New York, NY

Idelalisib, ibrutinib, and venetoclax have somewhat different toxicity profiles, and the time-to-event characteristics also tend to vary with the individual drugs. With idelalisib, warnings include fatal and/or severe diarrhea or colitis, hepatotoxicity, pneumonitis, and intestinal perforation. Liver toxicity tends to emerge relatively early, usually occurring within the first 12 weeks of treatment. In contrast, colitis tends to occur later rather than earlier, on the scale of approximately 6 months or more; and pneumonitis is more variable in its time-to-event characteristics. With ibrutinib, many of the toxicities tend to be earlier events, but some, such as hypertension, seem to occur in a percent-per-year–type incidence pattern that does not appear to diminish with time. But, the best approach to understanding these drugs is likely to examine the toxicities individually, and then try to define what the timeline for their emergence may or may not be. With regard to potential toxicities and kinase intolerance, comorbidities can be important with any of the novel agents. In the case of venetoclax, tumor lysis syndrome is a concern, especially in the setting of bulky disease and/or elevated absolute lymphocyte count and reduced renal function.

“The best approach to understanding these drugs is likely to examine the toxicities individually, and then try to define what the timeline for their emergence may or may not be.”

Anthony Mato, MD, MSCE

Age-associated comorbidities can be important considerations with any of the novel treatments for CLL. With advancing age, the increased potential for cardiac comorbidities is a concern for patients on ibrutinib, as there is an increased risk of atrial fibrillation and hypertension associated with this drug. There is also an increased risk of bleeding that may be enhanced in the setting of anticoagulation in patients with cardiac comorbidities. Some of the toxicities associated with idelalisib appear to be immune-based and more severe in younger patients, but patients should be monitored for liver problems or colitis-type comorbidities, as these are problematic with idelalisib. Renal function should be monitored in patients on venetoclax, since older patients may have reduced renal function, and the risk of tumor lysis syndrome increases with impaired renal function and with bulky disease.

“Age-associated comorbidities can be important considerations with any of the novel treatments for CLL.”

Anthony Mato, MD, MSCE

References

Coutré SE, Barrientos JC, Brown JR, et al. Management of adverse events associated with idelalisib treatment: expert panel opinion. Leuk Lymphoma. 2015;56(10):2779-2786. 

Mato AR, Nabhan C, Thompson MC, et al. Toxicities and outcomes of 616 ibrutinib-treated patients in the United States: a real-world analysis. Haematologica. 2018;103(5):874-879. 

Mato AR, Samp JC, Gauthier G, Terasawa E, Brander DM. Drivers of treatment patterns in patients with chronic lymphocytic leukemia stopping ibrutinib or idelalisib therapies. Cancer Biol Ther. 2018;19(7):636-643. 

Thompson PA, Stingo F, Keating MJ, et al. Outcomes of patients with chronic lymphocytic leukemia treated with first-line idelalisib plus rituximab after cessation of treatment for toxicity. Cancer. 2016;122(16):2505-2511.

Anthony R. Mato, MD, MSCE

Director, Chronic Lymphocytic Leukemia Program
Associate Attending, Memorial Sloan Kettering Cancer Center
New York, NY

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