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Hampel PJ, Call TG, Rabe KG, Ding W, Muchtar E, Kenderian SS, Wang Y, Leis JF, Witzig TE, Koehler AB, Fonder AL, Schwager SM, Van Dyke DL, Braggio E, Slager SL, Kay NE, Parikh SA. Disease Flare During Temporary Interruption of Ibrutinib Therapy in Patients with Chronic Lymphocytic Leukemia. Oncologist 2020; 25:974-980. [PMID: 32886416 DOI: 10.1634/theoncologist.2020-0388] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Approximately 25% of patients with chronic lymphocytic leukemia (CLL) experience a flare of disease following ibrutinib discontinuation. A critical question is whether this phenomenon may also occur when ibrutinib is temporarily held. This study aimed to determine the frequency and characteristics of disease flares in this setting and assess risk factors and clinical outcomes. MATERIALS AND METHODS We identified all patients with CLL seen at Mayo Clinic between October 2012 and March 2019 who received ibrutinib. Temporary interruptions in treatment and associated clinical findings were ascertained. RESULTS Among the 372 patients identified, 143 (38%) had at least one temporary interruption (median 1 hold, range 1-7 holds) in treatment. The median duration of interruption was 8 days (range 1-59 days) and the most common indication was periprocedural. Among the 143 patients with ≥1 hold, an associated disease flare was seen in 35 (25%) patients: mild (constitutional symptoms only) in 21 patients and severe (constitutional symptoms with exam/radiographic findings or laboratory changes) in 14 patients. Disease flare resolved with resuming ibrutinib in all patients. Predictive factors of disease flare included progressive disease at time of hold and ≥ 24 months of ibrutinib exposure. The occurrence of disease flare with an ibrutinib hold was associated with shorter event-free survival (hazard ratio 2.3; 95% confidence interval 1.3-4.1; p = .007) but not overall survival. CONCLUSION Temporary interruptions in ibrutinib treatment of patients with CLL are common, and one quarter of patients who held ibrutinib in this study experienced a disease flare. Resolution with resuming ibrutinib underscores the importance of awareness of this phenomenon for optimal management. IMPLICATIONS FOR PRACTICE Ibrutinib is a very effective treatment for chronic lymphocytic leukemia (CLL) but needs to be taken continuously. Side effects, such as increased bleeding risk with procedures, require temporary interruptions in this continuous treatment. Rapid CLL progression following ibrutinib discontinuation has been increasingly recognized. This study demonstrates that similar flares in disease signs or symptoms may occur during ibrutinib holds as well. Importantly, management with restarting ibrutinib led to quick clinical improvement. Awareness of this phenomenon among clinicians is critical to avoid associated patient morbidity and premature cessation of effective treatment with ibrutinib if the flare is misidentified as true progression of disease.
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Affiliation(s)
- Paul J Hampel
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy G Call
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kari G Rabe
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Wei Ding
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eli Muchtar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Saad S Kenderian
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yucai Wang
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jose F Leis
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas E Witzig
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amber B Koehler
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amie L Fonder
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Susan M Schwager
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel L Van Dyke
- Division of Laboratory Genetics and Genomics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Esteban Braggio
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Susan L Slager
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Neil E Kay
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Hampel PJ, Call TG, Ding W, Muchtar E, Kenderian SS, Wang Y, Leis JF, Witzig TE, Koehler AB, Fonder AL, Schwager SM, Rabe KG, Van Dyke DL, Braggio E, Slager SL, Kay NE, Parikh SA. Addition of venetoclax at time of progression in ibrutinib-treated patients with chronic lymphocytic leukemia: Combination therapy to prevent ibrutinib flare. Am J Hematol 2020; 95:E57-E60. [PMID: 31788844 DOI: 10.1002/ajh.25690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 11/26/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Paul J. Hampel
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Timothy G. Call
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Wei Ding
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Eli Muchtar
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Saad S. Kenderian
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Yucai Wang
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Jose F. Leis
- Department of Hematology and OncologyMayo Clinic Phoenix Arizona
| | - Thomas E. Witzig
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Amber B. Koehler
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Amie L. Fonder
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Susan M. Schwager
- Division of Biomedical Statistics & Informatics, Department of Health Sciences ResearchMayo Clinic Rochester Minnesota
| | - Kari G. Rabe
- Division of Biomedical Statistics & Informatics, Department of Health Sciences ResearchMayo Clinic Rochester Minnesota
| | - Daniel L. Van Dyke
- Department of Laboratory Medicine and PathologyMayo Clinic Rochester Minnesota
| | - Esteban Braggio
- Department of Hematology and OncologyMayo Clinic Phoenix Arizona
| | - Susan L. Slager
- Division of Biomedical Statistics & Informatics, Department of Health Sciences ResearchMayo Clinic Rochester Minnesota
| | - Neil E. Kay
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
| | - Sameer A. Parikh
- Division of Hematology, Department of MedicineMayo Clinic Rochester Minnesota
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