Jacqueline Claudia Barrientos, MD
Combinations with chemotherapy and immunotherapy have historically not been an attractive approach for elderly patients with chronic lymphocytic leukemia (CLL), due to the comorbidities these patients likely already have.
OncLive: Can you provide an overview of your presentation on the management of elderly patients with CLL?
The most important thing to understand is that elderly patients have many comorbidities that may affect their ability to tolerate a particularly therapy in CLL. By the time that these patients require therapy, most of them have at least 4 comorbidities, such as high blood pressure, cardiac disease, or are at high risk for kidney or liver disease.
The new era of drugs target the signaling pathway that is overexpressed and causes cell proliferation and survival of the malignant clone. This approach is better than chemotherapy, which is tough for many patients—particularly the elderly—to tolerate.
What are the more common comorbidities that elderly patients with CLL may have?
The most common comorbidity is hypertension, which should be monitored. We are seeing over time that patients treated with ibrutinib can experience hypertension. Due to that, if the blood pressure is not controlled, the patient could be at risk for other side effects.
Additionally, many patients have cardiac risk factors that require them to be on antithrombotic agents or anticoagulants. Single-agent ibrutinib can cause higher prevalence and propensity to bleed. It is important to recognize this and tell patients to stop ibrutinib before they need surgical intervention to minimize the risk for bleeding. We do not know which patients will bleed, so we have a blanket statement for everyone. If they have surgery, they should stop the drug 3 to 7 days before and after and should not initiate any new treatment without discussing it with the physician.
If a patient is on an antifungal agent, it may affect the ability to metabolize an oral agent because the dose has been metabolized by the liver.
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