CLL — Deciding Which BTK Inhibitor is Best in the Upfront Setting

The choice may come down to comorbidities

• Patients with migraines may not be good candidates for acalabrutinib (brand name: Calquence), which can worsen these headaches
• However, those with AFib may do better on acalabrutinib
• Switching from one BTK inhibitor may not be helpful because they have the same resistance mechanism

Chronic lymphocytic leukemia (CLL) patients now have several frontline treatment options available to them, including two FDA-approved Bruton tyrosine kinase (BTK) inhibitors: ibrutinib (brand name: Imbruvica) and acalabrutinib (brand name: Calquence). How do you determine which of these medications is best for a particular patient?

“A lot of the decision comes down to what comorbidities the patient has,” Dr. James Gerson, hematologist-oncologist at Penn Medicine, tells SurvivorNet Connect. “For example, a patient with terrible intractable migraines is probably not the best patient for acalabrutinib, because I’d worry that it would worsen those headaches.”

On the other hand, a patient with a history of atrial fibrillation (AFib) might do better on acalabrutinib because it’s associated with a lower AFib risk. “If the bleeding history is significant, you might shy away from either drug, because there’s not a zero risk with acalabrutinib,” he adds.

Most of the time, Dr. Gerson won’t switch from one of these drugs to the other because the two BTK inhibitors have the same resistance mechanism. “The majority of the time I’m picking one, and that’s the only one that they’ll receive,” he says. “The patients who stop responding to one are very unlikely to respond to the other.”