What are some of the major side effects of treatment that patients should be prepared for?

CLL Typically is a disease of B cells and a cell B cell is one which is not functional and at the same time it can the treatments that we use can affect all B cells, and that's one of the reasons that they are very high likelihood.

Infections both because of the disease and because of the treatment?

Second is bleeding of different types that can cause affect the heart. Sometimes some of these diseases can affect some of this treatment, can also affect it cause the GI issues and liver issues and so on. So they have to be monitored.

in 2023 there are many treatment options for CLL. The field has rapidly change and so we rarely ever use chemotherapy. It's really reserved for select patients. And so there's kind of two main classes of treatment options.

So I'll talk about the side effects for for those kind of classes of treatment in general. One of the major really advances for CLL and other related B-cell malignancies have been BTK or BRUTON'S tyrosine kinase inhibitors. These are drugs like ibrutinib at caliber NIBS and Abbott nerve that are FDA approved for CLL, both as first treatment and also for CLL.

If you haven't had this drug in the relapsed setting after other prior treatment. So this class of drugs is a pill based treatment. Right? And as a class, you know, there's a little bit of differences between the different drugs, between a brute near the caliber and Zana ibrutinib, but they do share some commonalities in the overall side effects.

So one of the major things we see with really is side effects with all alcohol treatment, as these treatments do have the ability to decrease the blood counts sometimes often before they get better. And so you might have lower hemoglobin, lower platelets, in some cases lower white blood cell count.

However, actually with the BTK inhibitors, these drugs, often when a patient first starts the drug, we actually see the white blood cell count go up even further. There's something called a lymphocyte ptosis or the lymphocyte count increases because interestingly, the seal drug works by you can think you have seal cells and lymph nodes. It's working. It's actually releasing some of the seal cells from the lymph nodes and pushing them out into the blood compartment. So I always tell patients to expect that, you know, right after they start the BTK inhibitors.

And it's not that they're not that the treatment's not working, but really an expected byproduct of starting a drug. The other major side effects that we can see are there is an increased risk of bleeding with these drugs. And so, you know, for patients who are on a blood thinner already, we have a discussion about the safety of that, whether it makes sense for the patient to do this or another treatment option. But there are patients that can safely do both.

And then if patients are scheduled for procedures, say there's a skin cancer that needs to be removed or some other type of dental work or some other type of operation, patients often will need to hold the drug for a period before and after the procedure. So it's really important to talk to your doctor and let them know that that procedure is happening.

The other thing that we've seen with BTK inhibitors is that they can have cardiovascular side effects and so they can increase the blood pressure. So that's something that we very carefully monitor at our visit. And often for patients with preexisting heart issues or hypertension, high blood pressure, I'll actually have a discussion with the cardiologist or primary care physician before they actually start that drug to make sure that we have a good plan.

Should we encounter higher blood pressure. And then the other risk we talk a lot about is the risk for a heart arrhythmia or atrial fibrillation. This is an abnormal heartbeat. It's common in the general population, but we actually do see a higher rate in patients who take a route, EVA caliber numbers. And there's some differences between each drug. And sometimes we select the drug based on the patient.

There does look like a Bruton If this risk is higher, we know now than with the caliber numbers and our burden. And so again, for patients who have a history of AFib or other heart condition, I really usually do do a cardiac evaluation before and work with a cardiologist to make sure that we have a safe plan going into starting the treatment. Is there anything patients can do to lessen or better manage these side effects?

most patients actually, while there's a host of side effects that come up, I would say, you know, in general, patients tolerate the side effects really well. I think it's always a good idea to talk to your doctor and the health care team, the nurses, nurse practitioners, pharmacists, if available, or to kind of know what the side effects are and just have a plan to call your doctor if they come up.

But I will say actually many patients start the drug and don't have any side effects. And some of these side effects, like the high blood pressure, can be cumulative over time. But some of the other side effects for example, I calibrate NIB many times patients will get a headache in the first few weeks of taking the drug, it responds well to Tylenol caffeine and then it often goes away.

really, again, staying attuned to the side effects. But you might, you know, as a patient start the drug and not experience any side effects. And these are pill based medicines that patients are able to take, you know, once or twice a day, depending on which one is selected for you, but often tolerated very, very well.

Additional steps you should take to limit side effects. Follow up fundamentally important, they should be vaccinated appropriately. Flu and COVID every year, for example, following the recommendations for pneumonia. Vaccines are very important. And then, of course, trying to avoid sources of infection.

Those those can definitely help subtypes. Patients are treated with something like rituximab. It's a rather simple drug. And in those cases they're trying to really decrease the clone, so called the cells of cells so that those bad effects are not occurring.

In those cases. You are really depleting not just CLL, but also other B cells. And these are part of the subset of immune cells which can fight infections. So as a result, you are more susceptible to infections.

The other toxic effects, for example, there are some small molecules called Bruton IB and that family, for example, they they are they're very effective in treating CML. They can control the disease very well, but they have untoward side effects which are not related directly to cell but to bleeding. And patients have to be aware of those.

Some of the drugs can also have toxicities related to food intake, and taking it in relation to food can decrease or increase toxicities. Those are typically minor, but yeah, depending on the drug, the infections are obviously the communists will fight by themselves. Clell itself can cause infections are more risk of infections. Some of these treatments can also increase the likelihood of infections and bleeding.

As it improved to that, the more involved multi-drug chemotherapies have standard chemotherapy side effects, peripheral properties, infections. Again, sometimes diarrhea and vomiting. Some of the drugs that are used for treating CLL can also cause diarrhea and that has to be again discussed with our colleagues is where the dose modifications are warranted.