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How I Managed 2 Challenging Patients With CLL During the COVID-19 Pandemic

John Pagel Headshot
John Pagel, MD, PhD

Chief of Hematologic Malignancies
Swedish Cancer Institute
Seattle, Washington

John Pagel, MD, PhD, has disclosed that he has received consulting fees from AstraZeneca, BeiGene, Gilead Sciences, and Loxo.

View ClinicalThoughts from this Author

Released: November 13, 2020

Clearly, the COVID‑19 pandemic has affected how we approach and treat all of our patients in medicine, and for me, the focus has been on my patients with chronic lymphocytic leukemia (CLL). We really have to be very careful about how we approach patients, and patients with CLL, in particular, as these patients may be among those at high risk for complications if they develop COVID-19. This is an important consideration when planning follow-up and treatment.

During the COVID-19 pandemic, it has been critical to limit exposure as much as possible and part of that, of course, is to avoid frequent clinic visits for these patients even if they are receiving treatment. Many of our treatment regimens in the past have required multiple visits to the clinic for either therapy and/or assessment with laboratory analyses. However, as a result of the COVID‑19 pandemic, we have evolved our approaches in an attempt to keep patients safe and out of the clinic as much as possible even when they require treatment. My general approach has been to avoid infusions when possible and to obtain laboratory work at outside facilities and then coordinate care through telehealth visits.

Managing an Older Patient Who Requires Therapy for CLL During the Pandemic
We recognize that most patients with CLL are a bit older. In fact, I had a recent patient who was 80 years of age who needed treatment for her CLL, and as one would expect, she did not want to come into the clinic due to the risk of exposure to COVID‑19. We devised a plan where the patient would get single‑agent oral therapy with a BTK inhibitor as an outpatient and that she would have laboratory work drawn locally with her primary care physician. I would review the labs, and then the patient and I would do video visits or telehealth visits every few months for management moving forward. Specifically, we remained focused on the presence of any symptoms or signs of progressive disease or treatment intolerance. This worked beautifully and she has done extremely well. I have actually only seen her once since we started therapy during the COVID‑19 pandemic.

When a Patient Develops COVID-19 While Receiving Treatment for CLL
Of course, we have had patients with CLL who have developed coronavirus infection. I had a very interesting and important case involving a gentleman with high‑risk CLL with a 17p deletion, who had been doing very well on single‑agent venetoclax after prior relapsed disease. He is a bit older and he was admitted to the hospital due to shortness of breath and worsening pulmonary function with COVID-19 and was managed with supportive care and continued the venetoclax. He also was enrolled on a clinical trial where he received remdesivir, the antiviral therapy directed towards the virus. Unfortunately, his viral illness continued to progress, his pulmonary status declined, and we actually treated this gentleman with tocilizumab, the anti–IL-6 receptor antagonist. This controlled the hyperinflammatory pulmonary clinical situation with a dramatic turnaround in his clinical status. He received 3 doses of tocilizumab and improved enough to be discharged from the intensive care unit after a couple of days. Following that, a short stay as an inpatient on the regular hospital ward led to his subsequent discharge from the hospital and now he has completely recovered a couple of months after that event. We kept him on his venetoclax as well for his CLL and he is doing quite well at this time in terms of his CLL and has fully recovered from his COVID-19 illness.

Your Thoughts?
What have been your biggest challenges in managing patients with CLL during the pandemic? Please join the discussion by sharing your experiences in the comment box!

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