NCCN Guidelines for Patients® | Chronic Lymphocytic Leukemia

38 NCCN Guidelines for Patients ® : Chronic Lymphocytic Leukemia, 2018 4 Treatment guide CLL without del(17p) or TP53 mutation Treatment for CLL without del(17p) or TP53 mutation Guide 3 lists first-time treatment options for older or younger sick people who have CLL that isn’t missing parts of chromosome 17 or has a TP53 mutation. The treatment options are listed in order of preference of NCCN experts. Your doctors may think you cannot withstand purine analogs. This type of chemotherapy increases the likelihood of serious infections. Purine-analogs include fludarabine, cladribine, and pentostatin. Purine analogs can reduce normal white blood cells to very low levels. It can take years for some white blood cells to increase to normal levels. If you take purine analogs, you may increase your chances for getting life-threatening infections. Compared to purine analogs, there are safer treatment options if you are physically frail and overall quite sick. Some of these treatments consist of both targeted therapy and chemotherapy. They include obinutuzumab with chlorambucil, ofatumumab with chlorambucil, and rituximab with chlorambucil. The second drug listed in Guide 3 is ibrutinib. It is a targeted drug and is included based on good results in well-designed clinical trials. Other options include taking a pulse corticosteroid with rituximab corticosteroids given in high doses over 3 to 5 days. One combination in Guide 3 includes HDMP and rituximab. Obinutuzumab, rituximab, and chlorambucil may each be used as a single agent to treat CLL. Chlorambucil by itself is the least preferred option. After first-line treatment, your doctor may consider maintenance therapy with lenalidomide if you are at high risk for the disease to relapse (come back). Your doctor will test for MRD after first-line treatment. MRD is when a very small amount of leukemia cells remains in your body after a course of treatment. With MRD, the amount of leukemia cells left is too small to be seen with a microscope. Thus, further treatment may be given. Guide 3. Treatments excluding purine analogs Frail and sick Treatment options (best options listed first) • Obinutuzumab + chlorambucil • Ibrutinib • Ofatumumab + chlorambucil • Rituximab + chlorambucil • Obinutuzumab • HDMP ( h igh- d ose m ethyl p rednisolone) + rituximab • Rituximab • Chlorambucil