Version October 2024
| Step 1: Evaluate exposure to prior therapies and response to therapy: | ||
| Initial therapy | Response to initial therapy | Preferred next treatment options |
| BTK inhibitor | Refractory | Venetoclax-based therapy |
| Intolerant | Venetoclax-based therapy* or Alternative BTK inhibitor (if no BTK mutation present) | |
| Venetoclax plus obinutuzumab | Early progression | BTK inhibitor |
| Late progression | Venetoclax-based therapy (if no BCL2 mutation present)* or BTK inhibitor | |
| Chemoimmunotherapy | Any | Venetoclax-based therapy* or BTK inhibitor |
| Step 2: Consider adverse events and administration concerns of interest: | ||
| BTK inhibitor | Continuous therapy; increases the risk for bleeding, atrial fibrillation, and hypertension; other toxicities include fatigue, rash, infections, and myalgias/arthralgias; numerous drug interactions | |
| Venetoclax plus obinutuzumab | Time-limited treatment; requires risk-based TLS prophylaxis and monitoring; most common toxicities include neutropenia, thrombocytopenia, anemia, diarrhea, nausea, upper respiratory tract infection, cough, musculoskeletal pain, fatigue, and edema; numerous drug interactions | |
| Step 3: Consider patient characteristics impacting choice of therapy: | ||
| Venetoclax-based therapy preferred over BTK inhibitor |
| |
| BTK inhibitor preferred over venetoclax-based therapy¶ |
| |
BTK: Bruton tyrosine kinase; CYP: cytochrome P450; TLS: tumor lysis syndrome.
* Venetoclax-based therapy and BTK inhibitors are equally acceptable next treatment options in this scenario.
¶ A BTK inhibitor may be preferred over venetoclax in patients with impaired creatine clearance and in those on strong CYP3A inhibitors due to an increased risk of TLS; however, BTK inhibitors are also CYP3A substrates, and dose adjustment or avoidance may be warranted, depending on the agent. Refer to drug interactions program.Do you want to add Medilib to your home screen?
