Ask the CLL Pharmacist - July 2021
It has been said countless times that there is no such thing as a bad question. One important benefit of asking questions is that others often have the same or similar question, but they never asked.
As a pharmacist and fellow chronic lymphocytic leukemia patient, I try to answer your questions based on my more than forty years of experience as a Registered Pharmacist.
My answers are based on my professional training and experience, but they are not a substitute for discussion with your medical team.
Question
I just ate one tangelo, part grapefruit, and part orange. I am on calquence. Is this a problem? Should I skip my night pill? Please help, very much appreciated
CLL Pharmacist Answer
Rest Easy!
You are in luck! Tangelos do not affect the CYP3A4 enzyme that metabolizes acalabrutinib (Calquence®). You are correct about grapefruit being a concern, but the hybrid of a tangerine and grapefruit known as a tangelo is not an issue.
The co-administration of grapefruit or Seville oranges causes drugs like acalabrutinib, ibrutinib (Imbruvica®), and venetoclax (Venclexta®) to accumulate in the bloodstream, leading to higher blood levels and potentially more side effects.
I hope this eases your mind! Enjoy your tangelos.
Ask the CLL Pharmacist Question
Does that mean that half of those vexed people are likely not protected at all, and a half probably is? Or that all of us have half as many antibodies, so we will likely get only 50% as sick as we could get? Or something different altogether? And is there a test we can take to determine if we did develop the appropriate level of antibodies? Thanks!
My Answer
You are not alone in being a bit confused by the COVID reports. I think that what is confusing is that essentially this data is comparing apples to oranges.
The data on the Pfizer vaccine came out of Israel, which was an early adopter of the vaccine and attained a significant percentage of vaccinated population early.
The 90+% efficacy cited for the general population refers to the ability of the vaccine to prevent serious illness and hospitalization. The 50% figure for blood cancer patients is for developing measurable antibodies that are part of the immune system that protects us from infection. The antibodies being tested are the b-cell response. Many blood cancers, including CLL effect the b-cells so we may not have the b-cell mediated immunity. This does not mean that we do not have the t-cell portion of the immune system working normally. The Leukemia and Lymphoma Society (LLS) is currently testing patients who did not show the initial antibody response to measure whether they mount a t-cell response. This will be an exciting report!
For those patients who did mount a b-cell response, nobody knows what number is protective against COVID infection. The test for antibodies can be found at this link: https://www.labcorp.com/tests/164090/sars-cov-2-semi-quantitative-total-antibody-spike.
One observation, I have made is based on a conversation with a Pulmonogist friend. He told me recently that he has not admitted a single patient for COVID who has been vaccinated in more than 90 days. He practices in several large hospitals in the Tampa area so he sees a lot of patients. With figures for how many people have compromised immune systems ranging from 3-5%, you would think he would see some immune compromised patients becoming ill with COVID. So my take-away is despite no antibodies we must have some protection.
My oncologist has told me that I could start treatment or wait. She has asked me to decide when to begin. Until recently, I managed some symptoms, but 3 wks ago, I just hit a wall with pain, fatigue, and shortness of breath. My lab results show WBCs are up, platelets are lower, and I’m a little anaemic. My spleen is a little enlarged, and so is my liver. What would be a deciding factor for treatment? I have had CLL for 16 yrs. Thanks for your input.
CLL Pharmacist Answer
It sounds to me like the time for treatment has arrived. The biggest factor is how you feel, not a specific number. I think that treatment will likely make you feel better in short order.
Your choices are essentially a standard of care medication or combination of medications or a clinical trial. There is a lot of benefit to venetoclax-containing combinations. It appears from my reading that venetoclax plus ibrutinib is the strongest available combo. I reached undetectable minimal residual disease (uMRD) on that combo. It is not yet FDA approved, but my insurance paid for it. To get that, you might need to be in a clinical trial.
Venetoclax plus obinutuzumab is another powerful combo. It is usually a one-year treatment, and a high percentage of patients reach uMRD. I have a friend who was in the trial of these two drugs before they were approved, and he has been CLL free and off medications for 3+ years.
GOOD LUCK! I hope you feel better
Ask the CLL Pharmacist
My granddaughter visited the other day, and we discussed how much coffee I could drink without hindering my hydration. So for each cup of coffee, do I need to add another cup of water? I like the idea of adding the coffee to the total rather than subtracting it.
Answer
Because caffeine is a diuretic, I only count half the volume in my fluid intake. So if I have a ten-ounce mug, I count it as five toward my daily intake. In actuality, caffeine is good with acalabrutinib because it reduces the incidence and severity of headaches, a common side effect.
The half rule is just my seat of the pants method of calculating based on my knowledge of the diuretic effects of caffeine. I do the same when I have an alcoholic beverage.