Questions submitted by readers and answered by the CLL Society Medical Advisory Board
Remember that we cannot give medical advice and any suggestions should be reviewed with your treating doctors.
By Thomas E Henry III, MBA, RPh, CPh
Can Imbruvica be taken every other day?
Here is the answer from Tom Henry, our pharmacist expert.
At the present time, I was not able to find any studies that support taking ibrutinib on an every other day cycle. Ibrutinib has a relatively short half life of 4 to 6 hours which means that half the remaining drug is eliminated from the system somewhere between 4 and 6 hours. In general, every other day dosing works with drugs with a longer half life exceeding 15-18hours. Based on general rules of pharmacodynamics and the lack of evidence-based research, I would think this potentially might not be a good approach.
There are a number of trials, albeit small trials that show that reduced doses even as low as 140mg daily are effective in managing CLL. In these trials patients received 420mg for 28 days, then 280mg for 28 days and then 140mg thereafter. There was no significant change in survival rates or progression free survival with this approach.
I would always caution you that you should discuss any change in dosage with your provider and not make changes on your own…
Additional note from Dr. Koffman: Hope that helps. I would add that the reduced dose studies that Tom quoted are not endorsed by some leading CLL experts.
I’m on Calquence and is it OK to take a Tylenol?
There should be no issue taking acetaminophen containing products such as Tylenol along with your Calquence. Because of the increased risk of bleeding with the two BTK inhibitors (Calquence and Imbruvica), acetaminophen is a good choice for pain relief or fever as opposed to aspirin or a non-steroidal anti-inflammatory product.
Acetaminophen should be used with caution as high doses are associated with liver toxicity. The latest FDA guidelines recommend not taking any single dose more than 650mg (2 – Regular Strength Tabs) and a maximum daily dose of 3000mg.
Is Melatonin safe for a person with CLL to take? I’ve heard both yes and no and wonder if I can take as a sleep aid.
There is no specific mention of melatonin in the package insert prescribing information for Ibrutinib relative to any warnings or potential drug interactions. CYP3A enzyme is not involved in the metabolism of this drug so it does not fall into that most serious drug interaction category.
There is actually some literature that mentions that there is a marked decrease in natural melatonin levels in CLL Patients.
And there is some research ongoing as to whether Melatonin may have some utility in cancer treatment and/or prevention.
There is some conflicting literature, that tends to be older, that melatonin may be detrimental relative to immune system issues.
Sleep disturbances are a commonly mentioned issue for CLL patients so melatonin may be of benefit. Personally, I have noticed a significant increase in sleep issues more related to waking up after only a few hours of sleep and I do take a time-release formulation which helps to some degree. I prefer this approach to taking a hypnotic product such as Ambien. I recommend clearing the addition of this product with your care team before adding it.
I received a notice from Humana that the 140 mg Imbruvica tablet will no longer be covered. Is the capsule the same as the tablet and is it still available?
Yes, there are no differences between the capsule and the tablet. The tablets were introduced as a patient convenience because the standard dose of 420mg required 3 capsules once a day. Unfortunately, they charged the same price per day of therapy regardless of the dose so a month of 140mg tablets cost the same as a month of 420mg tablets. The capsules also allowed dose reductions to be easier when experiencing side effects. Yes capsules are still available.
Hope that helps. The cost of the 140 mg tablet is 3 x the cost of the 140 mg capsule. The cost of the 420 mg tablet and capsule are the same as I understand.
I do not wish to take Aleve or any ibuprofen along with my 15 mg. of Xerelto. Tylenol doesn’t work as well for my knee joint that needs replacing. Please tell me I am correct to hesitate to take these two drugs together. I would really appreciate being helped with this.
You indicated that you are in watch and wait. Taking a drug like ibuprofen or Alleve has the potential to increase the risk of bleeding when taking with Xarelto. That being said, it would be less if of an issue if you took one tablet occasionally for pain. If your pain level is such that you would need a large dose or frequent doses pain medication, then it might be beneficial to discuss this with the physician who ordered the Xarelto initially to see if the dose of Xarelto could be lowered and then add regular dose of ibuprofen or Alleve.
I am about to start inbrutnib. My question is:
1. I take the thyroid med, Armour. Any concerns about taking with inbrutnib?
2. I ad hoc take Zicam, when I start to feel cold symptoms. Has worked really well. Any concerns about taking while on inbrutnib?
3. I like black chai tea, with spices like tumeric, ginger, cardomom, cinnamon, cloves, nutmeg, anise. Any concerns while on inbrutnib?
I see no problem with the thyroid medication.
Zicam is an “unapproved” homeopathic product that the FDA has issued warnings about using the nasal products because of potential for loss of smell. Because of limited understanding of how homeopathic products work or their potential to interact with allopathic (traditional) medications, I would recommend against using this product.
Ibrutinib has some blood thinning potential essentially about equivalent to a 325mg dose of Aspirin. Because every one of the spices you included in your list are natural blood thinners, you should consider avoiding or limiting your intake. Many CLL patients have low platelet counts so clotting of blood is already negatively affected and additional blood thinners can worsen bruising or outright bleeding.
Ibrutinib is a marvelous drug which controls CLL nicely for 90+% of patients. I hope the few lifestyle modifications listed here don’t diminish your desire to take Ibrutinib.
Thomas Henry is a Registered Pharmacist and CLL Patient. He is President and Senior Consultant for Burlington Consulting Associates, a company that provides consulting services to health systems nationwide. Tom is a CLL Society Medical Advisory Board member and strives to educate other CLL patients through his blog https//www.cllpharmacist.com. He has a forty-two-year career in pharmacy and has served as Chief Pharmacy Officer at two Top-15 Comprehensive Cancer Centers, Moffitt (Tampa, FL) and Roswell Park (Buffalo, NY).
Originally published in The CLL Tribune Q1 2019.