I'm seeing a 55 y/o M with new diagnosis of CLL, presented with WBC 250, Hgb 6.5, PLT 15, +splenomegaly on imaging. Is there any role for cytoreduction prior to starting BTKi given the expected initial rise in lymphocytosis on these agents? Alternatively, venetoclax-based therapy would be high risk for TLS so I am curious if you have a preferred approach when patients requiring treatment also present with high WBC.
I prefer BTKi, you can give dex 40 for 4 days for some cytoreduction but watch for TLS, or you can give a dose of obinu, even the first two days only would lower the peripheral lymphocytosis significantly. I am usually not concerned about that because lymphocytosis does not cause leukostasis usually.
