Paving the way for new agents; is standard chemotherapy part of the treatment paradigm for chronic lymphocytic leukemia in the future?

Autoimmune hemolytic anemia in adults: primary risk factors and diagnostic procedures

INTRODUCTION

Autoimmune hemolytic anemia (AIHA) is due to autoantibodies against erythrocytes that may arise either because of primary tolerance breakage or along with several associated conditions, including genetic predispositions, congenital syndromes, environmental triggers, autoimmune diseases, immunodeficiencies, and neoplasms.

AREAS COVERED

This review evaluated the risk of AIHA development in associated conditions and summarized disease-intrinsic risk factors for relapse and outcome. Diagnostic procedures were analyzed to properly identify primary and secondary forms. A Medline including clinical trials, meta-analyses, guidelines, consensus, and case reports, published in the last 30 years were performed.

EXPERT OPINION

The several associated conditions listed above constitute a risk for AIHA development and should be considered since disease course and therapy may be different. Particularly, AIHA developing after transplant or novel checkpoint inhibitors is an emerging complex entity whose proper therapy is still an unmet need. Concerning intrinsic risk factors, the severity of anemia at onset correlated with the recurrence of relapses, refractoriness, and fatal outcome. This finding reflects the presence of several mechanisms involved in AIHA, i.e. highly pathogenic antibodies, complement activation, and failure of marrow compensation. With the advent of novel target therapies (complement and various tyrosine kinase inhibitors), a risk-adapted therapy for AIHA is becoming fundamental.

Ibrutinib and its use in the treatment of chronic lymphocytic leukemia

Ibrutinib represents a revolution in chronic lymphocytic leukemia treatment scenario providing results never seen before and offering an effective therapy even in high-risk patients with really poor outcome after chemoimmunotherapy. Thanks to longer updates, on one hand, ibrutinib has confirmed its efficacy continuing to show clinical benefits over time; on the other hand, resistance mechanisms are slowly emerging. Moreover, clinicians should be aware of ibrutinib-related side effects, paying attention to screen patients that could benefit more from the drug and try to prevent adverse events. While ibrutinib approval indication is expanding, high treatment costs will shortly require a selection of those who can really draw advantage from Bruton's tyrosine kinase inhibition and those who could continue to be treated with chemoimmunotherapy.