Supportive or Palliative Care for Chronic Lymphocytic Leukemia

Although treating the CLL directly (with targeted drugs, chemotherapy, and/or immunotherapy) may help with some of the problems related to CLL over time, other treatments may be needed in the meantime.

Treatments to help prevent infections

People with CLL often have weakened immune systems. This can be from the CLL itself, as well as from some of the medicines used to treat it. Because of this, people with CLL are at higher risk for infections, which can sometimes be serious.

Antibiotic and antiviral medicines

Some medicines used to treat CLL, including some chemo drugs can raise your risk of certain infections such as cytomegalovirus (CMV) and pneumonia caused by Pneumocystis jiroveci.

You might be given an antiviral drug like acyclovir or valacyclovir to help lower your risk of CMV infection. To help prevent Pneumocystis pneumonia, a sulfa antibiotic is often given (such as trimethoprim with sulfamethoxazole). Other treatments are available for people who are allergic to sulfa drugs.

Some drugs used to treat CLL can also cause dormant viruses to become active. For instance, if you already carry the hepatitis B virus (HBV) or CMV, CLL treatment may allow them to grow and cause problems. Blood tests will be done to watch virus levels. You might be given drugs to help keep these viruses under control.

Antibiotics, antiviral, and antifungal drugs are also used to treat infections. Often, active infections require higher doses or different drugs from those used to prevent infections.

Intravenous immunoglobulin (IVIG)

Some people with CLL don’t make enough antibodies (immunoglobulins) to fight infections.This can lead to repeated lung and/or sinus infections. Antibody levels can be checked with a blood test, and if they're low, antibodies from donors might be given into a vein (IV) to raise the levels and help prevent infections. These donated antibodies are called intravenous immunoglobulin (IVIG).

Most people with CLL don't usually need IVIG . If it is (such as in people who are getting a lot of infections), it's often given about once a month at first, and then less often over time. IVIG can also be given as needed based on blood tests of antibody levels.

Vaccines

Vaccines to help prevent certain infections are often an important part of the care for people with CLL. But there might be times when vaccines might not be recommended, such as when you're being treated with medicines that weaken your immune system (which could make vaccines less effective). If you have CLL, it's best to speak to your health care provider before getting any vaccine.

Some examples of vaccines usually recommended for people with CLL include yearly flu (influenza) shots, COVID-19 vaccines, the pneumococcal vaccine (to help prevent pneumonia), and the recombinant zoster vaccine (to help prevent shingles). 

It's important for people with weak immune systems to avoid vaccines that contain live viruses. These vaccines can sometimes cause serious infections in people with weak immune systems.

For more information on vaccines, see Vaccinations and Flu Shots for People with Cancer.

Treatments for low blood counts

CLL or its treatment can cause low blood cell counts, especially red blood cells and platelets, which normally help the blood clot.

Having a low red blood count (anemia) can make you feel tired, lightheaded, or short of breath. Anemia can have different causes. If anemia is causing symptoms, it can be treated with red blood cell transfusions. These are often given in an outpatient clinic.

Having a low platelet count can lead to serious bleeding. Platelet transfusions can help prevent this.

In some people with CLL, low red blood and platelet counts can also be caused by the cells being destroyed by abnormal antibodies.

When antibodies cause low numbers of platelets, it's called immune thrombocytopenia (ITP). Before diagnosing this, the bone marrow is often checked to make sure that something else isn’t causing the low platelet counts. In ITP, giving platelet transfusions doesn’t usually help increase the platelet counts, because the antibodies just destroy the new platelets, too. This can be treated with drugs that affect the immune system, like corticosteroids, IVIG, and the antibody drug rituximab. Another option is to remove the spleen, since after the antibodies stick to the platelets, they're actually destroyed in the spleen.

When antibodies cause low red blood cell counts, it's called autoimmune hemolytic anemia (AIHA). This also can be treated with drugs that affect the immune system, like corticosteroids, IVIG, and rituximab. Removing the spleen is another option. Sometimes AIHA can develop while you're getting certain drugs, so stopping the drug may be helpful.

Treating very high white blood cell counts (leukapheresis)

Although it's rare, some people with CLL have very high numbers of leukemia cells in their blood when they're first diagnosed, which causes problems with their blood circulation. This is called leukostasis, and it needs to be treated right away.

Sometimes treating CLL with medicines such as targeted drugs, chemotherapy, and/or immunotherapy might not lower the number of leukemia cells right away. Because of this, a procedure called leukapheresis may be used first. In this treatment, your blood is passed through a special machine that takes out the white blood cells (including leukemia cells) and returns the rest of the blood back into your bloodstream.

Two intravenous (IV) lines are needed for this treatment − the blood is removed through one IV, and then returned to your body through the other IV. Sometimes, a single large catheter is put in near the neck or under the collar bone − instead of using IV lines in the arms. This type of catheter is called a central venous catheter (CVC) or central line and has both IVs built into it.

Leukapheresis works quickly to get the number of leukemia cells down. The effect is only for a short time, but it may help until other treatments have a chance to work.