Internal Medicine

0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

Chronic Lymphocytic Leukemia 335

management

What to Do First

■To decide if the patient needs treatment

Indications

■Disease related symptoms (weight loss, fever, fatigue)

■Progressive increase in lymphocytosis with a rapid LDT

■Worsening of anemia and or thrombocytopenia

■Auto-immune anemia or thrombocytopenia

■Symptomatic bulky lymphadenopathy or splenomegaly

■Recurrent infections

Treatment Strategy Based on Stage

■Low risk and Intermediate risk - Observation, unless any of the above

indication is present

■High risk – Initiate cytotoxic therapy

specific therapy

■Chlorambucil PO Q 3–4 weeks or

■Cyclophosphamide PO/iv Q3–4 weeks or

■Fludarabine iv QD×5 days q month for 4–6 months

■Glucocorticoids: Prednisone alone or combination with alkylating

agents (not with Fludarabine)

■Monoclonal antibodies:

➣Campath-1H (anti-CD52) – for Fludarabine failures given iv or sc

at 30 mg each dose 3 times a week (usually Mondays, Wednesdays

and Fridays) for up to 8 weeks

➣Rituximab (anti-CD20) (in clinical trials) – In combination with

fludarabine (given at standard dosage as described above, on

monthly basis), and rituximab given on day 1 of each month’s

fludarabine, at 375 mg/M2 iv, for 4–6 months

follow-up

During Treatment

■CBC and physical exam at 2–3 weeks

■Coombs, quantitative immunoglobulins periodically

■Bone marrow biopsy at complete remission (CR) by all other criteria

Routine

■Once in CR: CBC, physical exam q 2–3 months