In regards to Venetoclax ramp-up, the package insert says to do a slow, weekly ramp-up. I've done accelerated, daily ramp-ups in patients with AML without having any issues with TLS. I have a refractory CLL patient that I am starting on Venetoclax+Rituximab, and I've been told that CLL patients have an increased risk of TLS compared to AML when initiating venetoclax. Is it recommended to do the slow, weekly Venetoclax ramp-up for CLL patients or can an accelerated ramp-up be safely used?
Yes CLL patients are at a uniquely high risk for TLS with venetoclax given CLLs dependence upon BCL2 (much much much more than AML). We have done accelerated ramp ups in CLL but we generally do not. Unless the patient is floridly relapsing and the benefit of fast ramp up outweighs the risk of TLS I wouldn’t escalate quicker than the PI. In cases where we have had rapidly progressing patients and we felt they needed to get to 400 mg quickly, we would admit the patient and obtain q8 hour TLS labs, provide TLS prophy with fluids, and escalate every 48 hours if no signs of TLS until up to 400 mg.
