Cardiovascular and Bleeding Risk With BTK Inhibitors in CLL

M. Yair Levy, MD, of Texas Oncology–Baylor Charles A. Sammons Cancer Center, explains that second-generation Bruton tyrosine kinase (BTK) inhibitors have more focused kinase profiles, so acalabrutinib and zanubrutinib carry a better cardiovascular profile than ibrutinib and are favored in guidelines. Andrew H. Lipsky, MD, of Columbia University Irving Medical Center, says bleeding concerns are less frightening than in the early days: he routinely combines BTK inhibitors with anticoagulation, sometimes reducing the apixaban dose, and treats warfarin as an absolute contraindication and dual antiplatelet therapy as a strong relative contraindication. Asked by Sameh Gaballa, MD, of Moffitt Cancer Center, about baseline cardiac assessment, Dr Lipsky does little for the average patient beyond an occasional electrocardiogram, reserving cardio-oncology referral for prior cardiac events, and uses the runway before treatment to optimize fitness. Dr Levy works with primary care or cardiology to control blood pressure, lipids, and glucose.