NCCN Guidelines for Patients® | Chronic Lymphocytic Leukemia
24 NCCN Guidelines for Patients ® : Chronic Lymphocytic Leukemia, 2019 3 Treatment guide Relapsed or refractory CLL c yclophosphamide, r ituximab) did not work any better than fludarabine-based chemoimmunotherapy. When used alone, rituximab or chlorambucil does not work as well as other treatments among older or really ill people. But, the side effects of these treatments are not severe. Maintenance After immunochemotherapy, your doctor may give you lenalidomide for maintenance treatment. It is sometimes given if the cancer is likely to relapse. Relapse is more likely if very small amounts of cancer cells remain in your blood after treatment. This small amount is called MRD ( m inimal r esidual d isease). Relapsed or refractory CLL Before starting treatment, your doctor may want to test the cancer again. Important markers are del(17p), TP53 mutation, and karyotype. Imaging may also be done. If CLL is now a different type of cancer, read the section, Transformed CLL , in this chapter. Options for relapsed or refractory CLL are listed in Guide 3 . Ibrutinib, venetoclax with rituximab, duvelisib, and idelalisib with rituximab are preferred for all types of CLL no matter your age or health. Venetoclax is also a preferred treatment for CLL with del(17p) or a TP53 mutation. The other options listed have had some good results. A clinical trial and allogeneic stem cell transplant may be options. Ask your doctor if there is an open clinical trial. For a transplant, you must not have major health problems other than the cancer. Maintenance If remission is achieved, your doctor may start you on maintenance treatment. Lenalidomide is sometimes given if very small amounts of cancer cells (MRD) remain in your blood after treatment. Another option for maintenance treatment is ofatumumab, but more research on it is needed. What to expect: Ibrutinib ü Is taken once a day around the same time. ü Is made as tablets and capsules. ü May cause an increase in lymphocytes even when treatment is working. ü Can cause side effects, such as tiredness, fever, rash, nausea, diarrhea, pain, bleeding, and heart problems. ü Should not be stopped unless your doctor tells you to stop.