Supporting Daily Well-Being During CLL Treatment With Calquence and Brukinsa
Monitoring the CLL for progression, helping the patient to adhere to the medication regimen, preventing and managing infections, cardiovascular events, and assessing and managing the risk of bleeding are important aspects of the patient’s treatment and care. Monitoring of laboratory values, patient’s nutritional status, physical activity, and overall quality of life also are very important.
Calquence (acalabrutinib) and Brukinsa (zanubrutinib) are Bruton tyrosine kinase (BTK) inhibitors approved by the U.S. Food and Drug Administration for the treatment of adults with Chronic Lymphocytic Leukemia (CLL) or Small Lymphocytic Lymphoma (SLL).
Medication Adherence and Daily Routines
If a patient is taking Calquence Brukinsa, adherence to daily administration at a fixed time of the day is an important aspect of treatment management. Patients are required to take their medication in the exact dose as prescribed by their treating physicians. The healthcare team must be notified of any inability to take the prescribed dose. Patients must never attempt to alter their dosage of either of these two cancer therapies without first consulting with their treating health care team for guidance.
Review the patient’s current list of medications. List the dose for each medication and the frequency of each. The patient might be taking a multitude of different medications, in addition to their BTK inhibitors. There are also a multitude of over-the-counter (OTC) products and/or dietary supplements that the patient might be taking. Each of these (prescribed as well as OTC/dietary supplements) must be reviewed by the clinician to look for potential drug interactions. For some of the medications/dietary supplements, it might be advisable for the patient to avoid using them altogether. For others, it may be necessary to decrease the dose of the prescribed medication(s) in order to avoid ‘too much of a good thing’. For others, decreasing the frequency of administration of a particular medication(s) might be in the patient’s best interest.
This list of drug interactions for both Calquence and Brukinsa should be updated and reviewed with the patient and their family for all of their current prescription, non-prescription, and over the counter (OTC) medications, as well as for any supplements they are currently taking.
Monitoring for Infection
Patients on treatment for CLL are immune compromised and as such are at greater risk for serious and opportunistic infections. addition to the treatment of the leukemia itself, the CLL patient needs special care to protect them from and to treat infections. Patients and their families and caregivers can be taught to recognize and report such symptoms. Early recognition of infection is key to management.
As with other serious and potentially life-threatening infections, there are warnings for Brukinsa and Calquence regarding serious and opportunistic infections, etc. Infection should be considered in any CLL patient who develops a new symptom or worsening of existing symptoms including persistent or recurrent fever or chills, increasing cough or shortness of breath, or other new symptoms. Further investigation and/or treatment with antibiotics, or even consideration of a treatment hold, may be necessary. Live vaccines should not be given to patients on cancer treatment who have impaired immune function. However, individualized vaccine plans should be made.
Managing Bleeding Risk
Unusual bruising or bleeding can be a sign of an increased risk of bleeding when taking a BTK inhibitor. Unusual bleeding or blood in urine/stool must be reported to the physician. The warnings and precautions for Calquence and Brukinsa for hemorrhage are important to note.
A patient’s other treatments for health problems can affect their risk for bleeding while on a BTK inhibitor. A patient who is on anticoagulants or antiplatelets for example would have an increased risk for bleeding while on a BTK inhibitor for the treatment of CLL. All of a patient’s current treatments must be reviewed by a healthcare professional to assess potential drug interactions and to determine the appropriate course of treatment.
Similar considerations would apply for other procedures that are invasive in nature, and might need to be managed on an individual basis according to the patient’s circumstances and in line with the prescribing information for the patient’s BTK inhibitor.
Cardiovascular Health
Monitor patients with CLL for signs and symptoms of cardiac arrhythmias, including atrial fibrillation and atrial flutter. Additional monitoring may be considered in patients with a history of cardiac arrhythmias or cardiovascular risk factors such as hypertension, acute infections, or patients receiving medications that may increase blood pressure.
Cardiac arrhythmias, including atrial fibrillation/atrial flutter, can occur and be associated with symptoms such as palpitations, dizziness, fainting, shortness of breath and chest discomfort. A full cardiovascular history should be taken and patients with cardiovascular risk factors (e.g. hypertension), and those with previous arrhythmias, monitored for symptoms of cardiac arrhythmias during periods of acute infection.
Blood Counts and Laboratory Monitoring
Monitoring Blood Counts, particularly a Complete Blood Count (CBC) and platelet count is very important. Neutropenia (low white blood cells) and Anemia (low red blood cells) as well as Thrombocytopenia (low platelets) can occur. Monitoring of blood counts prior to and during treatment is recommended.
Monitor liver enzymes, and for signs of hepatotoxicity including drug-induced liver injury (DILI). For Brukinsa, monitor before starting treatment, after first month on treatment, and then every 2 months on treatment. For Calquence, monitor as clinically indicated.
Nutrition, Activity and Fatigue
Assess for all potentially reversible causes of fatigue in people with cancer. Maintain nutrition, keep patients well hydrated, and where appropriate increase level of physical activity to support overall health of patient receiving treatment for their CLL.
It is very important for patients with cancer to maintain good nutrition and adequate fluid intake while on treatment. Maintaining physical activity is also very important to help patients with CLL maintain strength, mobility and the highest level of functioning possible while on treatment. However, each patient should have their activity level individualized based on age, overall health, prior level of activity, symptoms, low blood counts or other complications from their cancer treatment.
Skin Protection and Long-Term Health
Second primary malignancies, including non-melanoma skin cancers, have been reported. Monitor for development of second malignancies and manage accordingly. Skin protection should be a routine aspect of the care of patients on these agents and any new or changing skin lesions should be assessed by the patient’s healthcare provider.
By limiting the amount of time a patient on BTK-inhibitors spends outside during peak sun hours and by advising them on proper sun protection, the risk of non-melanoma skin cancers may be decreased. Any changes in the skin need to be reported to the treating physician.
Supporting Quality of Life
In addition to reviewing the lab values to see how well the CLL is being controlled, assess the patient’s daily functioning (e.g. sleep, fatigue, affect, appetite, activity level, work, social activity).
Patients with CLL are also in need of support to manage their treatment. Support can be given with issues related to treatment such as remembering to take the medication, transport to and from appointments, attending appointments with the patient and communication with health care professionals.
A Patient-Centered Approach to CLL Treatment
Both Calquence Brukinsa may be considered for patients with CLL and with or without prior therapies. Patients however are all very different and treatment decisions therefore need to take into account individual patients’ characteristics, including their CLL and other co-morbidities, on-going therapies, laboratory values and personal circumstances.
Monitoring patients on BTK inhibitors for CLL can be viewed within the framework of supportive care. Supportive care may not only help patients manage treatment side effects but could also maintain daily functioning during therapy. Patients on BTK inhibitors should not change or discontinue their CLL treatment without speaking with their treating healthcare professional.
Early intervention and supportive care may help to manage treatment-related side effects, support daily functioning, and assist patients in managing their CLL treatment.
Medical Disclaimer: The information provided in this article is intended for educational purposes only and should not be interpreted as medical advice, clinical guidelines, or a recommendation for any specific treatment.