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Is it unreasonable to just start with rituximab, then if poor or incomplete result resort to the other antibody treatments?

Ask the Doctor Question:

First diagnosed with CLL in 2007 on Watch and Wait for 6-months, then had FCR light for two rounds. Lymphocytes dropped so significantly that I stopped the chemo after two rounds of the planned six rounds. Thereafter on remission until February 2014. After two rounds of rituximab, my blood chemistry looked well enough to stop further infusions. Coming back out of remission and now looking at treatment options. Preferred regimens offered are:

  • Acalabrutinib
  • Ibrutinib
  • Venetoclax and rituximab
  • Duvelisib
  • Idelalisib and rituximab

Is it unreasonable to just start with rituximab, then if poor or incomplete result resort to the other antibody treatments?

Answer: What has your CLL Specialist advised? You mentioned starting with a single monotherapy antibody treatment and then switching to another one if that one didn’t work. Monotherapy rituximab (R) is typically used more in community/rural oncology practices than at the larger academic centers. You may be doing this already, but please make sure you are seeing a CLL Specialist and have received all of the appropriate testing needed prior to the initiation of any new therapy to determine what your best treatment plan should be. That is of the utmost importance so you and your healthcare provider can partake in shared decision making regarding your next choice for treatment.

Generally, ibrutinib has become one of the gold standards for CLL in recent years since the side effects are so much lower than previous options and it is an oral therapy that doesn’t require an infusion center. And acalabrutinib has an even lower side effect profile. Since rituximab is an infusion, it can lead to transfusion reactions as well as increase the likelihood of tumor lysis syndrome.

Single-agent rituximab only showed modest activity in previously treated and untreated CLL. And the combination of ibrutinib with rituximab has not shown any additional clinical benefit when compared to just treating with ibrutinib alone.