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Patel R, Singh A, Meng Z, Baldridge AS, Addison D, Akhter N. The risk vs. benefit calculus of anticoagulation in patients with ibrutinib-related atrial fibrillation. Leuk Lymphoma 2024; 65:168-174. [PMID: 37953609 PMCID: PMC10952122 DOI: 10.1080/10428194.2023.2278433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/29/2023] [Indexed: 11/14/2023]
Abstract
For ibrutinib-related atrial fibrillation (IRAF), guidelines for anticoagulation do not exist. We sought to describe stroke, bleeding, and anticoagulation rates among patients with IRAF. We performed a single-center retrospective review of 168 patients treated with ibrutinib followed from 2013 to 2022. Over a median follow-up of 6.4 years, 44 (26.0%) patients developed IRAF of which 38 (86.4%) had a CHA2DS2-VASc ≥2 and 7 (15.9%) had a HAS-BLED ≥3. Anticoagulation was initiated in 20 (45.5%) without a clear pattern in scores, risk factors, or cumulative dose, besides having another reason for anticoagulation. Few patients with IRAF developed non-hemorrhagic CVA (n = 3, 6.8%) or significant bleeding (n = 3, 6.8%). Among those with each adverse outcome, 2 in each group were anticoagulated and all were older than 65 years old. In conclusion, decisions for anticoagulation vary widely and patients who are elderly or with HTN may be most at risk for CVA or significant bleed.
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Affiliation(s)
- Ruchi Patel
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Arushi Singh
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Zhiying Meng
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Abigail S. Baldridge
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Addison
- Division of Cardiology, CardioOncology Program, The Ohio State University Medical Center, Columbus, OH
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiovascular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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2
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Wei C, Fazal M, Loh A, Kapoor R, Gomez SE, Shah S, Rogers AJ, Narayan SM, Wang PJ, Witteles RM, Perino AC, Cheng P, Rhee JW, Baykaner T. Comparative arrhythmia patterns among patients on tyrosine kinase inhibitors. J Interv Card Electrophysiol 2024; 67:111-118. [PMID: 37256462 PMCID: PMC10851950 DOI: 10.1007/s10840-023-01575-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/16/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Tyrosine kinase inhibitors (TKIs) are widely used in the treatment of hematologic malignancies. Limited studies have shown an association between treatment-limiting arrhythmias and TKI, particularly ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor. We sought to comprehensively assess the arrhythmia burden in patients receiving ibrutinib vs non-BTK TKI vs non-TKI therapies. METHODS We performed a retrospective analysis of consecutive patients who received long-term cardiac event monitors while on ibrutinib, non-BTK TKIs, or non-TKI therapy for a hematologic malignancy between 2014 and 2022. RESULTS One hundred ninety-three patients with hematologic malignancies were included (ibrutinib = 72, non-BTK TKI = 46, non-TKI therapy = 75). The average duration of TKI therapy was 32 months in the ibrutinib group vs 64 months in the non-BTK TKI group (p = 0.003). The ibrutinib group had a higher prevalence of atrial fibrillation (n = 32 [44%]) compared to the non-BTK TKI (n = 7 [15%], p = 0.001) and non-TKI (n = 15 [20%], p = 0.002) groups. Similarly, the prevalence of non-sustained ventricular tachycardia was higher in the ibrutinib group (n = 31, 43%) than the non-BTK TKI (n = 8 [17%], p = 0.004) and non-TKI groups (n = 20 [27%], p = 0.04). TKI therapy was held in 25% (n = 18) of patients on ibrutinib vs 4% (n = 2) on non-BTK TKIs (p = 0.005) secondary to arrhythmias. CONCLUSIONS In this large retrospective analysis of patients with hematologic malignancies, patients receiving ibrutinib had a higher prevalence of atrial and ventricular arrhythmias compared to those receiving other TKI, with a higher rate of treatment interruption due to arrhythmias.
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Affiliation(s)
- Chen Wei
- Department of Internal Medicine, Stanford University, Stanford, CA, USA
| | - Muhammad Fazal
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA
| | - Alexander Loh
- Department of Internal Medicine, Kaiser Permanente Santa Clara Homestead Medical Center, Santa Clara, CA, USA
| | - Ridhima Kapoor
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA
| | - Sofia Elena Gomez
- Department of Internal Medicine, Stanford University, Stanford, CA, USA
| | - Shayena Shah
- Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Albert J Rogers
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA
| | - Sanjiv M Narayan
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA
| | - Paul J Wang
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA
| | - Ronald M Witteles
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA
| | - Alexander C Perino
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA
| | - Paul Cheng
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA
| | - June-Wha Rhee
- Division of Cardiology, Department of Medicine, City of Hope Comprehensive Medical Center, Duarte, CA, USA.
| | - Tina Baykaner
- Department of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Room 334C, Stanford, CA, 94304, USA.
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Fariman S, Momeni Nasab F, Faraji H, Afzali M. Cost-Effectiveness of Ibrutinib as First-line Treatment for Older Patients With Chronic Lymphocytic Leukemia in Iran. Value Health Reg Issues 2023; 38:93-100. [PMID: 37806264 DOI: 10.1016/j.vhri.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/11/2023] [Accepted: 08/02/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVES We aimed to evaluate the cost-effectiveness of ibrutinib versus chemoimmunotherapy for frontline treatment of elderly patients with chronic lymphocytic leukemia in Iran. METHODS We developed a partitioned survival model with 3 health states (progression-free survival, post-progression survival, and death) and a lifetime horizon. State memberships were determined by parametric survival analysis of the ALLIANCE (A041202) randomized controlled trial's results, comparing first-line ibrutinib with bendamustine plus rituximab. Direct medical costs were calculated from an Iranian health system perspective. Utility values were extracted from the literature to calculate the incremental costs and quality-adjusted life-years (QALYs) associated with each strategy. To address parameter uncertainties, deterministic and probabilistic sensitivity analyses were also performed. RESULTS In the base-case analysis, ibrutinib and bendamustine plus rituximab were associated with $3739.72 and $3991.20 costs per patient as the first-line treatment strategy, respectively. They resulted in an average of 2.86 and 2.66 QALYs per patient. Thus, first-line ibrutinib was associated with 0.20 incremental QALY and $251.48 cost-saving per patient and was therefore the "dominant" strategy. In deterministic sensitivity analysis, drug prices were the key drivers of model outputs. However, none of the resulting incremental cost-effectiveness ratios exceeded the currently accepted threshold by the Iranian Food and Drug Administration ($1550 per QALY). In probabilistic sensitivity analysis, 63.3% of iterations were cost-saving and 77.4% were cost-effective. CONCLUSIONS Our findings suggest that ibrutinib as a first-line treatment appears to be the dominant strategy, compared with the standard of care, for unselected older adults with chronic lymphocytic leukemia in Iran.
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Affiliation(s)
- Soroush Fariman
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Pharmaceutical Strategic Analysis and Research (PASAR), Tehran, Iran; Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina Chapel Hill, NC, USA
| | - Fatemeh Momeni Nasab
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Pharmaceutical Strategic Analysis and Research (PASAR), Tehran, Iran
| | - Hoda Faraji
- Department of Pharmacoeconomics and Pharmaceutical administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran; Pharmaceutical Strategic Analysis and Research (PASAR), Tehran, Iran
| | - Monireh Afzali
- Pharmaceutical Strategic Analysis and Research (PASAR), Tehran, Iran.
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Aghel N, Baro Vila RC, Lui M, Hillis C, Leong DP. Diagnosis and Management of Cardiovascular Effects of Bruton's Tyrosine Kinase Inhibitors. Curr Cardiol Rep 2023; 25:941-958. [PMID: 37498449 DOI: 10.1007/s11886-023-01916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW Bruton's tyrosine kinase inhibitors (BTKis) have changed the treatment and prognosis of several B-cell malignancies. However, since the approval of the first BTKi, ibrutinib, reports of cardiovascular adverse events especially atrial fibrillation have arisen. In this review, we discuss the cardiovascular side effects of BTKis and the management of these toxicities in clinical practice. RECENT FINDINGS BTKIs increase the risks of atrial fibrillation, bleeding, hypertension, heart failure, and potentially ventricular arrhythmia. Newer second and third-generation BTKis appear to have a lower risk of cardiovascular adverse events; however, long-term follow-up data are not available for these new BTKis. BTKis are an effective treatment for some B-cell malignancies; however, they can cause cardiovascular side effects. The best preventive strategies to minimize cardiovascular complications remain undefined. Currently, a practical approach for managing patients receiving BTKis includes the management of cardiovascular risk factors and side effects of BTKis to prevent interruption of cancer treatment.
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Affiliation(s)
- Nazanin Aghel
- The Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
- McMaster University, Hamilton, ON, Canada.
| | - Rocio C Baro Vila
- McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires ICBA, Buenos Aires, Argentina
| | | | | | - Darryl P Leong
- The Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- McMaster University, Hamilton, ON, Canada
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Prasad RM, Layne J, Oleski M, Rodriguez L, Grimm R, Klein A, Cutler D, Collier P. Severe Spontaneous Echocardiographic Contrast in a Patient With Normal Heart and Chronic Lymphocytic Lymphoma. CASE (Phila) 2023; 7:273-277. [PMID: 37546363 PMCID: PMC10403630 DOI: 10.1016/j.case.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
•SEC can occur in a structurally and functionally normal heart. •SEC formation has a stoichiometric relationship between hematocrit and fibrinogen levels. •SEC may be underappreciated in hematologic malignancies after chemotherapy initiation.
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Affiliation(s)
- Rahul M. Prasad
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Jessica Layne
- Department of Cardiology, Cleveland Clinic Akron General, Akron, Ohio
| | - Michael Oleski
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Leonardo Rodriguez
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard Grimm
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allan Klein
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - David Cutler
- Department of Cardiology, Cleveland Clinic Akron General, Akron, Ohio
| | - Patrick Collier
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Nixon S, Duquette D, Doucette S, Larouche JF. How We Manage Patients with Indolent B-Cell Malignancies on Bruton's Tyrosine Kinase Inhibitors: Practical Considerations for Nurses and Pharmacists. Curr Oncol 2023; 30:4222-4245. [PMID: 37185435 PMCID: PMC10137400 DOI: 10.3390/curroncol30040322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
The most common forms of B-cell malignancy, non-Hodgkin lymphoma (NHL) and chronic lymphocytic leukemia (CLL), have seen a drastic shift in the treatment landscape over the last two decades with the introduction of targeted agents. Among them are Bruton's tyrosine kinase (BTK) inhibitors, which have demonstrated excellent efficacy in indolent B-cell NHLs and CLL. Although BTK inhibitors are generally thought to be more tolerable than chemoimmunotherapy, they are associated with a unique safety profile including varying rates of rash, diarrhea, musculoskeletal events, cardiovascular events, and bleeding. Ibrutinib was the first BTK inhibitor to gain a Health Canada indication, followed by second-generation BTK inhibitors acalabrutinib and zanubrutinib, which have better safety profiles compared to ibrutinib, likely due to their improved selectivity for BTK. As BTK inhibitors are oral agents given continuously until disease progression, long-term adverse event (AE) monitoring and management as well as polypharmacy considerations are important for maintaining patient quality of life. This paper intends to serve as a reference for Canadian nurses and pharmacists on dosing, co-administration, and AE management strategies when caring for patients with indolent B-cell NHL or CLL being treated with BTK inhibitors.
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Affiliation(s)
- Shannon Nixon
- Malignant Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
| | - Dominic Duquette
- Department of Pharmacy, Hôpital de l'Enfant-Jésus, CHU de Québec-Université Laval, Quebec City, QC G1J 1Z4, Canada
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Narezkina A, Akhter N, Lu X, Emond B, Panjabi S, Forbes SP, Hilts A, Liu S, Lafeuille MH, Lefebvre P, Huang Q, Choi M. Real-World Persistence and Time to Next Treatment With Ibrutinib in Patients With Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Including Patients at High Risk for Atrial Fibrillation or Stroke. Clin Lymphoma Myeloma Leuk 2022; 22:e959-e971. [PMID: 35973891 DOI: 10.1016/j.clml.2022.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/24/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a recognized adverse consequence associated with all Bruton's tyrosine kinase inhibitors used to treat chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL); however, real-world time to discontinuation (TTD) and time to next treatment (TTNT) of CLL/SLL patients with a high baseline AF/stroke risk remain unknown. MATERIALS AND METHODS Patients with CLL/SLL from a nationwide electronic health record-derived database (February 12, 2013-January 31, 2021) initiating first-line (1L) or second or later-line (2L+) treatment with ibrutinib or other regimens on or after February 12, 2014 (index date) were analyzed. Kaplan-Meier survival analysis was used to assess TTD and TTNT among all patients, patients with high AF risk (CHARGE-AF risk score ≥10.0%), and patients at high risk of stroke (CHA2DS2-VASc risk score ≥3 [females] or ≥2 [males]). RESULTS In 1L/2L+, 2190/1851 patients received ibrutinib and 4388/4135, were treated with other regimens. Median TTD for ibrutinib was similar regardless of AF/stroke-related risk (1L: all patients, 15.7 months; high AF risk, 11.7 months; high stroke risk, 13.7 months; similar results in 2L+). Median TTNT was significantly longer for ibrutinib vs. other regimens (1L: not reached vs. 45.9 months; 2L+: not reached vs. 23.6 months; both P < .05), including among those with high AF/stroke risk. TTNT was similar between all patients and high-risk cohorts in 1L and 2L+ (all P > .05). CONCLUSION This study highlights that elevated baseline AF/stroke-related risk does not adversely impact TTD and TTNT outcomes associated with ibrutinib use. Additionally, TTNT was significantly longer for patients treated with ibrutinib vs. other regimens.
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Affiliation(s)
- Anna Narezkina
- University of California San Diego Health, San Diego, CA
| | | | - Xiaoxiao Lu
- Janssen Scientific Affairs, LLC, Horsham, PA
| | - Bruno Emond
- Analysis Group, Inc., Montréal, Québec, Canada.
| | | | | | | | | | | | | | - Qing Huang
- Janssen Scientific Affairs, LLC, Horsham, PA
| | - Michael Choi
- University of California San Diego Moores Cancer Center, San Diego, CA
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8
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Dong R, Yan Y, Zeng X, Lin N, Tan B. Ibrutinib-Associated Cardiotoxicity: From the Pharmaceutical to the Clinical. Drug Des Devel Ther 2022; 16:3225-3239. [PMID: 36164415 PMCID: PMC9508996 DOI: 10.2147/dddt.s377697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/06/2022] [Indexed: 12/06/2022] Open
Abstract
Ibrutinib is the first-in-class Bruton tyrosine kinase (BTK) inhibitor that has revolutionized the treatment of B cell malignancies. Unfortunately, increased incidences of cardiotoxicity have limited its use. Despite over a decade of research, the biological mechanisms underlying ibrutinib cardiotoxicity remain unclear. In this review, we discuss the pharmacological properties of ibrutinib, the incidence and mechanisms of ibrutinib-induced cardiotoxicity, and practical management to prevent and treat this condition. We also synopsize and discuss the cardiovascular adverse effects related to other more selective BTK inhibitors, which may guide the selection of appropriate BTK inhibitors.
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Affiliation(s)
- Rong Dong
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
| | - Youyou Yan
- Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
| | - Nengming Lin
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
- Nengming Lin, Department of Clinical Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Room 903, No. 7 Building, Hangzhou, People’s Republic of China, Tel/Fax +86-571-56005600, Email
| | - Biqin Tan
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Correspondence: Biqin Tan, Department of Clinical Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Room 207, No. 5 Building, Hangzhou, People’s Republic of China, Tel +86-571-56007824, Fax +86-571-56005600, Email
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St-Pierre F, Ma S. Use of BTK Inhibitors in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL): A Practical Guidance. Blood Lymphat Cancer 2022; 12:81-98. [PMID: 35911566 PMCID: PMC9325877 DOI: 10.2147/blctt.s326627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022] Open
Abstract
The treatment landscape of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) has changed significantly since the development of oral Bruton’s tyrosine kinase (BTK) inhibitors. While chemoimmunotherapy was previously the standard of care for first-line treatment, BTK inhibitors have proven to be a highly effective and safe therapeutic option for CLL/SLL, and now constitute one of the preferred first-line options. Ibrutinib, the first approved covalent BTK inhibitor in CLL/SLL, has the most long-term data supporting its efficacy in CLL/SLL treatment although is associated with increased risk of cardiovascular and hemorrhage adverse events due to off-target kinase inhibition. The second-generation covalent BTK inhibitors, including acalabrutinib and zanubrutinib, are more selective to BTK with less off-target effects. Resistance to covalent BTK inhibitors may emerge over time due to mutations in BTK and downstream kinases. Novel non-covalent BTK inhibitors currently being studied are showing promising activities to overcome such resistance. In this review, we discuss the role of BTK inhibitors in treatment of CLL/SLL, review the data that led to approval of BTK inhibitors in CLL/SLL, outline the toxicity profile of each approved BTK inhibitor and management, and give practical guidance on how to select the most appropriate agent for treatment.
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Affiliation(s)
- Frédérique St-Pierre
- Department of Medicine, Division of Hematology/Oncology and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Shuo Ma
- Department of Medicine, Division of Hematology/Oncology and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
- Department of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Correspondence: Shuo Ma, Division of Hematology-Oncology, Department of Medicine, Feinberg School of Medicine and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Tel +1 312-695-0990, Email
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Abstract
Cancer and cardiovascular diseases (CVD) are among the leading causes of death worldwide. In response to the growing population of cancer patients and survivors with CVD, the sub-specialty of cardio-oncology has been developed to better optimise their care. Palpitations are one of the most common presenting complaints seen in the emergency room or by the primary care provider or cardiologist. Palpitations are defined as a rapid pulsation or abnormally rapid or irregular beating of the heart and present a complex diagnostic entity with no evidence-based guidelines currently available. Palpitations are a frequent occurrence in people with cancer, and investigations and treatment are comparable to that in the general population although there are some nuances. Cancer patients are at a higher risk of arrhythmogenic causes of palpitations and non-arrhythmogenic causes of palpitations. This review will appraise the literature with regards to the development and management of palpitations in the cancer patient.
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Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart and Chest Hospital Liverpool, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart and Chest Hospital Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University Aalborg, Denmark
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Affiliation(s)
- Ridhima Kapoor
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Muhammad Fazal
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Paul Cheng
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald Witteles
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - June-Wha Rhee
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Tina Baykaner
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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