Dr. Raphael on Addressing the Risk of Tumor Lysis Syndrome in CLL

Bruce G. Raphael, MD, a clinical professor in the Department of Medicine at NYU Langone Health, discusses the risk of tumor lysis syndrome in chronic lymphocytic leukemia (CLL).

Sequencing is important because of the risk of tumor lysis syndrome (TLS). In the past, standard treatment options did not kill enough CLL cells, so TLS and its consequences were not understood as well. CLL is a slow disease, says Raphael. Now that more effective agents are available, particularly BCL-2 inhibitors, it is known that patients with a large tumor burden are more likely to develop TLS, particularly at the beginning of treatment, explains Raphael. In an effort to mitigate this, patients are now started on smaller doses of these agents, such as 20 mg. Then, the dose is increased to 400 mg over 1 to 2 months, adds Raphael.

However, if obinutuzumab (Gazyva) is used first, then there may be reduction of the tumor without TLS, adds Raphael. With other novel drug options, patients do not experience TLS. As such, in the protocol of an ECOG trial, all patients are started on obinutuzumab and ibrutinib(Imbruvica) and after 2 months of cytoreduction, venetoclax (Venclexta) is added, concludes Raphael.