Ask the Experts

Ask the Experts: Managing Targeted Therapy in Chronic Lymphocytic Leukemia

Sandra Kurtin, PhDc, ANP-C, AOCN

Practice Community
Tuscon, Arizona

Hospital and Institutional Affiliations
Nurse Practitioner, Assistant Professor of Clinical Medicine Adjunct Clinical Professor of Nursing The University of Arizona

Question 1.When a patient with chronic lymphocytic leukemia (CLL) is being treated with targeted therapy, what is your strategy for educating patients about adverse events?
My approach to any treatment is to explain the drug itself, why we are using it, and what the most common adverse events are, with a particular focus on those that need to be reported immediately—what I call reportable signs and symptoms—so that we can intervene quickly. Patients also get a booklet that includes a calendar and drug information that is specific to the drug itself. We have a very formal chemotherapy education program called Tailored Antineoplastic Therapy Program.
Question 2. When using targeted therapy in patients with chronic lymphocytic leukemia (CLL), what are some of the most typical side effects? How do you manage these adverse events when they occur? How does the multidisciplinary team determine when dosing adjustments are needed?
Monoclonal antibodies and targeted oral therapies, small molecules, have very unique toxicity profiles. For instance, with venetoclax we have to be cautious about tumor lysis syndrome, which is something that previously was not a big issue in chronic lymphocytic leukemia (CLL). With ibrutinib, there are atrial fibrillation and bleeding risks, which are not really a concern with other drugs. Idelalisib can cause transaminitis and other kinds of laboratory abnormalities that require close monitoring. The monoclonal antibodies are no different than other monoclonals, and the most common adverse event is hypersensitivity reactions. They all have the potential to cause cytopenias, but that is true of any drug that is used to treat a hematologic malignancy. Every drug has guidelines for dose modification based on adverse events or intolerance, and then you have to look at the individual patient. Some of that has to do with whether they are frail or fit, whether they have comorbidities (and other drugs that they may be taking for those comorbidities), and another consideration has to do with their marrow reserves.
Question 3. What is the strategy for first-line treatment of patients with a deletion in chromosome 17 in your clinic?
Standard chemotherapeutic agents do not work for patients who have 17p deletion mutations. When you look at a newly diagnosed patient, one of the first questions is, do they need treatment? Do they meet the guidelines for treatment, which are outlined by the International Working Group, and then, secondly, are they fit or frail? What can they handle? If they have a 17p deletion, you will likely use a drug like ibrutinib, because there is data and it is approved in the front-line setting. But, for regimens like fludarabine, cyclophosphamide, and rituximab (FCR), even in a fit patient, there are really no good data for long-term outcomes. Moving forward, researchers are beginning to look into the combination of these drugs in clinical trials. But, right now, there are only a few drugs that really have activity in 17p and that includes ibrutinib, venetoclax, or alemtuzumab.
Question 4. What are your methods for educating patients with CLL who are receiving targeted therapy about adherence? What is your advice for nurses who are struggling to keep their patients adherent?
Adherence is still an issue, with oral drugs in particular because all of the responsibility is with the patient. So, it is important to make it clear why they need to take it consistently. You have to make sure they understand that in order to achieve the outcomes that we see in clinical trials, you have to emulate the clinical trial. Another reason for nonadherence is cost, so we spend a lot of time upfront evaluating the patient’s out-of-pocket expense and determining if there are assistance programs available to help them financially. The third most common reason that people stop the drug is because of adverse events. For new patients who are starting a new drug, most of these side effects come early in the first couple months of therapy. Once they receive the drug we set up a series of visits, the first being 1 week out, and then 2 weeks out, and we keep those visits more frequent in the early weeks of treatment so you can talk to them about how it is going and if they are having trouble taking the drug — just working it out in their daily routine and reinforcing the teaching. We really work hard to reinforce that teaching and have them either come in or, if they live far away, do a phone follow-up for reinforcement. My advice for other nurses is to create a program that provides patients with organized education, gives them some tools, and discuss the reportable signs and symptoms so that they are not ending up in the emergency department or given the perception that the drug is too toxic.
Question 5. What do you feel are the most important topics for nurses who treat patients with CLL to be aware of?
The leading cause of death for patients with CLL is infection. So, we try to be very clear about reportable signs and symptoms. Also, it is important for patients to stay well so that they are fit enough to receive therapy, for that reason it’s important to talk about exercise, diet, and, in particular, infection prevention. Immunizations, what should they get, the things to avoid, which is the shingles vaccine since it’s a live virus. In the end, our focus is to keep them well, and in order to do that we must focus on their individual treatment plan and tailoring our education to their treatment. We would not have any of the drugs that we have without clinical trials, and I approach my practice with the idea that we never want to exclude a treatment option. That means that we need to keep people well enough so they can have these treatments, but also be aware of potential clinical trial options that may offer another option. There are still people who run out of options and so it’s important to try to encourage clinical trial participation.