Idelalisib induced CMV gastrointestinal disease: the need for vigilance with novel therapies

Herpesvirus Infections Potentiated by Biologics

Herpesviruses such as herpes simplex virus (HSV) type 1 and 2, varicella-zoster virus (VZV), and cytomegalovirus (CMV) maintain lifelong latency in the host after primary infection and can reactivate periodically either as asymptomatic viral shedding or as clinical disease. Immunosuppression, including biologic therapy, may increase frequency and severity of herpesvirus reactivation and infection. Licensed biologics are reviewed regarding their risks of potentiating HSV, VZV, and CMV reactivation and infection. Approaches to prophylaxis against HSV, VZV, and CMV infection or reactivation are discussed.

Novel Therapy Approaches to Follicular Lymphoma

Follicular lymphoma (FL) is the most common form of indolent non-Hodgkin lymphoma. It is a disease characterised by a long median overall survival and high response rates to currently available chemotherapy and anti-CD20 monoclonal antibody therapy combinations. However, for a sub-group of patients the disease behaves aggressively, fails to respond adequately to initial therapy or relapses early. For others, the disease becomes resistant following multiple lines of therapy, and despite recent advances the main cause of death for patients with FL remains their lymphoma. A wide landscape of novel therapies is emerging and the role of individual agents in the FL treatment paradigm is still being established. Some agents, including the cereblon modulator lenalidomide, the phosphatidylinositol 3-kinase inhibitors idelalisib, copanlisib and duvelisib, and the EZH2 inhibitor tazemetostat have received regulatory approval in the USA or European Union and have entered clinical practice for relapsed FL. Other developments, such as the emergence of immunotherapies including CAR-T cell therapy and bispecific antibodies, are expected to fundamentally change the approach to FL treatment in the future.

Invasive fungal infections in the immunocompromised host: Mechanistic insights in an era of changing immunotherapeutics

The use of cytotoxic chemotherapy in the treatment of malignant and inflammatory disorders is beset by considerable adverse effects related to nonspecific cytotoxicity. Accordingly, a mechanistic approach to therapeutics has evolved in recent times with small molecular inhibitors of intracellular signaling pathways involved in disease pathogenesis being developed for clinical use, some with unparalleled efficacy and tolerability. Nevertheless, there are emerging concerns regarding an association with certain small molecular inhibitors and opportunistic infections, including invasive fungal diseases. This is perhaps unsurprising, given that the molecular targets of such agents play fundamental and multifaceted roles in orchestrating innate and adaptive immune responses. Nevertheless, some small molecular inhibitors appear to possess intrinsic antifungal activity and may therefore represent novel therapeutic options in future. This is particularly important given that antifungal resistance is a significant, emerging concern. This paper is a comprehensive review of the state-of-the-art in the molecular immunology to fungal pathogens as applied to existing and emerging small molecular inhibitors.

Monitoring and Management of Toxicities of Novel B Cell Signaling Agents

PURPOSE REVIEW

B cell signaling agents, including ibrutinib, idelalisib, and the BCL-2 inhibitor venetoclax have become an integral part of therapy for patients with non-Hodgkin's lymphomas. The toxicity profiles of these medications is distinct from chemoimmunotherapy. Here, we will review the mechanism of action of these drugs, their efficacy, and toxicity management.

RECENT FINDINGS

Ibrutinib use is associated with increased risk of atrial fibrillation and bleeding which can be managed using dose interruptions and modifications. Patients on idelalisib require close clinical and frequent laboratory monitoring, particularly of liver function tests to ensure there are no serious adverse events. Monitoring for infections is important in patients on both idelalisib and ibrutinib. Venetoclax requires close clinical and laboratory monitoring to prevent significant tumor lysis. Targeted B cell receptor therapies each have unique side effect profiles which require careful clinical monitoring. As we continue to use these therapies, optimal management strategies will continue to be elucidated.