A 73-Year-Old Woman With Chronic Lymphocytic Leukemia - Episode 4

Monitoring and Managing Adverse Effects of CLL Therapy

Jeff Sharman, MD, shares insight into best practices for monitoring and managing adverse effects of treatment in chronic lymphocytic leukemia including elevated liver function tests, diarrhea, and pneumocystis pneumonia.

Jeff Sharman, MD: In terms of what to expect for patients on a PI3 kinase inhibitor, there are 2 main adverse effects we need to be cautious about. The first is an elevated liver function test. It tends to occur quite early, so the prescription information provides relatively detailed descriptions on how frequently we need to be monitoring liver function tests during the first several months. When patients have elevated liver function tests, it can be quite dramatic. You can see numbers that are significantly elevated. Holding the medication until those levels resolve, then you’re able to resume the idelalisib [Zydelig], and oftentimes—in fact, almost all the time—that does not come back. It tends to be a self-limited phenomenon.

The other issue is diarrhea. Diarrhea comes up as an adverse effect for many drugs. With idelalisib, it’s probably more related to immune function rather than pills or capsules or anything like that. It tends to be a later phenomenon. When patients develop diarrhea, it’s really an inflammatory diarrhea: almost like a colitis. It’s very important to warn patients about this in advance, because patients can get into quite a bit of trouble with the diarrhea. It’s important that they stop therapy immediately. Imodium loperamide is not necessarily the right intervention. In fact, conventionally we’ve used steroids in this situation. Some patients may need to be admitted for IV [intravenous] hydration. When patients have a really significant diarrhea event, oftentimes it’s a little harder to resume the medication thereafter. It can be done, but the experience isn’t as robust in that situation.

Patient education has to be 1 of the key features. If a patient reports diarrhea, particularly watery diarrhea—multiple loose stools per day—you want them to call you and let you know early on so they can stop treatment. If they keep pushing through, that diarrhea episode can get more severe. Finally, with idelalisib–rituximab [Rituxan], we generally monitor for CMD [congenital muscular dystrophy] reactivation, and we consider prophylaxis for PCP [phenylcyclohexyl piperidine] pneumonia so that we can avoid some of the infectious complications that can arise.

This transcript has been edited for clarity.