NCCN Guidelines for Patients® | Chronic Lymphocytic Leukemia
42 NCCN Guidelines for Patients ® : Chronic Lymphocytic Leukemia, 2018 4 Treatment guide CLL without del(17p) or TP53 mutation Guide 7. First-time treatments including purine analogs Older or quite sick Treatment options (best options listed first) • Obinutuzumab + chlorambucil • Ibrutinib • Ofatumumab + chlorambucil • Rituximab + chlorambucil • Bendamustine ± CD20 monoclonal antibody • Obinutuzumab • HDMP + rituximab • Rituximab • Chlorambucil Guide 7 lists first-time treatment options for older or younger sick people with CLL that isn’t missing parts of chromosome 17 or has a TP53 mutation. Your doctors may think you can withstand purine analogs. However, the first few options listed aren’t as harsh on your body as purine analogs. Obinutuzumab plus chlorambucil has been the standard of care for this group. It has had good results in well-designed clinical trials. The second drug listed in Guide 7 is ibrutinib. It is also included based on good results in well-designed clinical trials. Other options include ofatumumab with chlorambucil, rituximab with chlorambucil, bendamustine with or without CD20 monoclonal antibody (see page 31 for CD20 drugs), obinutuzumab, HDMP and rituximab, rituximab alone, or chlorambucil. Chlorambucil 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.