Updates in CLL: A Closer Look at Adverse Events - Episode 7
Carrie Lenneman, MD, MSCI, and Farrukh Awan, MD, review strategies for managing hypertension in patients with CLL.
Farrukh Awan, MD: One thing that I always wanted to know was, is there a magic to managing the hypertension? Is there a sequence of drugs that I should use? I know…amlodipine; I know I’m not to use diltiazem. For the β-blockers, I tend to stick with metoprolol because the other one….
Carrie Lenneman, MD, MSCI: Coreg [carvedilol] interacts, yes.
Farrukh Awan, MD: Yes, Coreg has an interaction. Carvedilol has an interaction, so I tend to stay with metoprolol. So do you have a formula? Which one should we start with, 1, 2, 3?
Carrie Lenneman, MD, MSCI: First I do a lot of counseling with my patients about living in the South, making sure they don’t eat a lot of sauce. I at least do that. So I usually am doing an ACE [angiotensin-converting enzyme inhibitor] or ARB [angiotensin receptor blocker], usually with a diuretic. That tends to be the most effective. That’s assuming they have normal renal function. If they don’t have normal renal function, I’ll usually use amlodipine. But then again as you get higher doses of amlodipine, they tend to have lower extremity edema. I forewarn them about that so they’re aware of it. Ideally, I like an ACE or ARB, usually with a diuretic first. Then metoprolol is good for heart rate control. It’s not a very good, effective antihypertensive. It’s not very potent to lower blood pressure, especially when you are dealing with pressures of 150s or 160s mm Hg; you’re not going to get a lot of bang for your buck with that. I don’t know if that gives you any insight into things.
Farrukh Awan, MD: I think I remember lisinopril and losartan.
Carrie Lenneman, MD, MSCI: Yes, and then maybe consider a diuretic, in some patients.
Farrukh Awan, MD: Hydrochlorothiazide,yes, I know.
Carrie Lenneman, MD, MSCI: If you find hydrochlorothiazide is not doing it, chlorthalidone is a little stronger. That’s a little secret in cardiology. We’ll switch people from HCTZ [hydrochlorothiazide] to chlorthalidone to get better blood pressure lowering.
Farrukh Awan, MD: One thing I would like to also mention, we did publish on this a few years ago. We need to have more of these data, and there are more data coming out with zanubrutinib and with acalabrutinib, and trials have been done and reported already. But the vast majority of patients who stop ibrutinib because of an adverse event tend not to have recurrence, or did not have recurrence of that particular adverse event when they switched to acalabrutinib. That’s how we initially were thinking more of switching the drug because of intolerance. I’m talking about even bleeding issues. In some patients where they had to stop because of atrial fibrillation, when they switched to acalabrutinib, that didn’t always necessarily recur. I think even in the really bad patients, once they recover from the adverse events, my practice has been to at least give the other agent a try. Zanubrutinib is part of the NCCN [National Comprehensive Cancer Network] list. It can be considered. It depends on if it gets approved or not. I have not had any problems using it in the right patient. So I feel that I would like to maximize our patients’ time on a BTK inhibitor, especially if it’s clinically effective. Then if they stop because of adverse events, once that resolves, try to use the other one and hope that they tolerate that. In most cases they do.
This transcript has been edited for clarity.