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Venetoclax: A Review in Previously Untreated Chronic Lymphocytic Leukaemia

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Abstract

Venetoclax (Venclexta®; Venclyxto®) is a first-in-class, oral, selective inhibitor of B cell lymphoma 2 (BCL2). In several countries, including the USA and those of the EU, venetoclax is indicated in combination with obinutuzumab for the treatment of adult patients with previously untreated chronic lymphocytic leukaemia (CLL). Approval was based on the results of the phase III CLL14 trial in patients with previously untreated CLL and co-existing conditions. In this study, fixed-duration (12 months) targeted treatment with venetoclax + obinutuzumab resulted in significantly longer progression-free survival (PFS; primary endpoint) relative to fixed-duration chemoimmunotherapy with chlorambucil + obinutuzumab. Venetoclax + obinutuzumab was also associated with significantly higher rates of undetectable minimal residual disease (MRD), complete response and overall response than chlorambucil + obinutuzumab. Improvements in clinical outcomes with venetoclax + obinutuzumab were maintained during long-term follow-up, when all patients had been off treatment for ≥ 2 years. No significant between-group difference was observed in overall survival (OS). Venetoclax had an acceptable tolerability profile. Notable adverse events such as grade 3 or 4 neutropenia can be managed with supportive therapy and venetoclax dose modifications. In conclusion, fixed-duration venetoclax + obinutuzumab represents an important chemotherapy-free first-line treatment option for patients with CLL, particularly those who are not fit enough to receive intensive chemoimmunotherapy.

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References

  1. Sengar M, Jain H, Rajendra A, et al. Frontline therapy of chronic lymphocytic leukemia: changing treatment paradigm. Curr Hematol Malig Rep. 2020;15(3):168–76.

    Article  Google Scholar 

  2. Eichhorst B, Robak T, Montserrat E, et al. Chronic lymphocytic leukaemia: ESMO clinical practice guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2020. https://doi.org/10.1016/j.annonc.2020.09.019.

    Article  PubMed  Google Scholar 

  3. Hallek M. Chronic lymphocytic leukemia: 2020 update on diagnosis, risk stratification and treatment. Am J Hematol. 2019;94(11):1266–87.

    Article  Google Scholar 

  4. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN Guidelines®): chronic lymphocytic leukaemia/small lymphocytic lymphoma. Version 1.2021. 2020. https://www.nccn.org. Accessed 19 Oct 2020.

  5. Von Tresckow J, Eichhorst B, Bahlo J, et al. The treatment of chronic lymphatic leukemia. Dtsch Arzebl Int. 2019;116(4):41–6.

    Google Scholar 

  6. Awan FT, Al-Sawaf O, Fischer K, et al. Current perspectives on therapy for chronic lymphocytic leukemia. Am Soc Clin Oncol Educ Book. 2020. https://doi.org/10.1200/EDBK_279099.

    Article  PubMed  Google Scholar 

  7. Hallek M, Cheson BD, Catovsky D, et al. iwCLL guidelines for diagnosis, indications for treatment, response assessment, and supportive management for CLL. Blood. 2018;131(25):2745–60.

    Article  CAS  Google Scholar 

  8. Adams CM, Clark-Garvey S, Porcu P, et al. Targeting the Bcl-2 family in B cell lymphoma. Front Oncol. 2019;8:636.

    Article  Google Scholar 

  9. Khan N, Kahl B. Targeting BCL-2 in hematologic malignancies. Target Oncol. 2018;13(3):257–67.

    Article  Google Scholar 

  10. AbbVie. VENCLEXTA (venetoclax): US prescribing information. 2019. https://www.dailymed.nlm.nih.gov. Accessed 19 Oct 2020.

  11. AbbVie. Venclyxto film-coated tablets: summary of product characteristics. 2019. https://www.ema.europa.eu. Accessed 19 Oct 2020.

  12. Scott LJ. Venetoclax: a review in relapsed/refractory chronic lymphocytic leukemia. Target Oncol. 2019;14(5):493–504.

    Article  Google Scholar 

  13. Fischer K, Al-Sawaf O, Bahlo J, et al. Venetoclax and obinutuzumab in patients with CLL and coexisting conditions. N Engl J Med. 2019;380(23):2225–36.

    Article  CAS  Google Scholar 

  14. Flinn IW, Gribben JG, Dyer MJS, et al. Phase 1b study of venetoclax-obinutuzumab in previously untreated and relapsed/refractory chronic lymphocytic leukemia. Blood. 2019;133(26):2765–75.

    Article  CAS  Google Scholar 

  15. Fischer K, Ritgen M, Al-Sawaf O, et al. Quantitative analysis of minimal residual disease (MRD) shows high rates of undetectable MRD after fixed-duration chemotherapy-free treatment and serves as surrogate marker for progression-free survival: a prospective analysis of the randomized CLL14 trial [abstract no. 36]. Blood. 2019;134(Suppl. 1):36.

    Article  Google Scholar 

  16. Al-Sawaf O, Gentile B, Devine J, et al. Rapid improvement of patient-reported outcomes with venetoclax plus obinutuzumab in patients with previously untreated CLL and coexisting conditions: a prospective analysis from the CLL14 trial [abstract no. 4305]. Blood. 2019;134(Suppl. 1).

  17. Al-Sawaf O, Zhang C, Tandon M, et al. Venetoclax plus obinutuzumab versus chlorambucil plus obinutuzumab for previously untreated chronic lymphocytic leukaemia (CLL14): follow-up results from a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2020;21(9):1188–200.

    Article  CAS  Google Scholar 

  18. Al-Sawaf O, Fink AM, Robrecht S, et al. Prevention and management of tumor lysis syndrome in patients with CLL and coexisting conditions treated with venetoclax-obinutuzumab or chlorambucil-obinutuzumab: results from the randomized CLL14 trial [abstract no. 4315]. Blood. 2019;134(Suppl. 1).

  19. Milunovic V, Misura Jakobac K, Mandac Rogulj I, et al. The fading star of obinutuzumab–chlorambucil regimen in patients with comorbidities with chronic lymphocytic leukemia—are we ready for chemo-free immunotherapy approach? Expert Rev Hematol. 2020;13(7):771–9.

    Article  CAS  Google Scholar 

  20. Schiattone L, Ghia P, Scarfo L. The evolving treatment landscape of chronic lymphocytic leukemia. Curr Opin Oncol. 2019;31(6):568–73.

    Article  CAS  Google Scholar 

  21. Cheson BD, Mato AR. The evolving use of minimal residual disease (MRD) assessment in chronic lymphocytic leukemia. Clin Adv Hematol Oncol. 2020;18(6):10.

    Google Scholar 

  22. Banerji V, Anglin P, Christofides A, et al. Updates from the American Society of Hematology 2019 annual meeting: practice-changing studies in treatment-naive chronic lymphocytic leukemia. Curr Oncol. 2020;27(2):e231–45.

    Article  CAS  Google Scholar 

  23. Seymour JF. Venetoclax plus obinutuzumab therapy for front-line treatment of chronic lymphocytic leukaemia. Lancet Oncol. 2020;21(9):1128–30.

    Article  CAS  Google Scholar 

  24. Davids MS, Huntington SF, Moreno C, et al. Indirect treatment comparison analysis of venetoclax + obinutuzumab with standard frontline regimens for chronic lymphocytic leukemia [abstract no. 2101 plus poster]. In: XVIII International Workshop on Chronic Lymphocytic Leukemia. 2019.

  25. Selvi P, Montero-Perez O, Portilo-Haro S. Indirect treatment comparisons of ibrutinib–obinotuzumab versus venetoclax–obinotuzumab in naive chronic lymphocytic leukaemia [abstract no. 4CPS-098]. Eur J Hosp Pharm. 2020;27(Suppl. 1):A93.

    Google Scholar 

  26. Sheng Z, Song S, Yu M, et al. Comparison of acalabrutinib plus obinutuzumab, ibrutinib plus obinutuzumab and venetoclax plus obinutuzumab for untreated CLL: a network meta-analysis. Leuk Lymphoma. 2020. https://doi.org/10.1080/10428194.2020.1811271.

    Article  PubMed  Google Scholar 

  27. Sudhapalli P, Piena M, Palaka A, et al. Systematic literature review and network meta-analysis comparing therapies for treatment-naive patients with chronic lymphocytic leukemia [abstract no. EP725]. HemaSphere. 2020;4(Suppl. 1):320.

    Google Scholar 

  28. Coll Bastus N, Davids MS, Huntington SF, et al. Indirect treatment comparison analysis of venetoclax + obinutuzumab with standard front-line regimens for chronic lymphocytic leukaemia. Br J Haematol. 2020;189(1):219–20.

    Google Scholar 

  29. Davids MS, Waweru C, Le Nouveau P, et al. Comparative efficacy of acalabrutinib in frontline treatment of chronic lymphocytic leukemia: a systematic review and network meta-analysis. Clin Ther. 2020. https://doi.org/10.1016/j.clinthera.2020.08.017.

    Article  PubMed  Google Scholar 

  30. Cho SK, Manzoor BS, Sail KR, et al. Budget impact of 12-month fixed treatment duration venetoclax in combination with obinutuzumab in previously untreated chronic lymphocytic leukemia patients in the United States. Pharmacoeconomics. 2020;38:941–51.

    Article  Google Scholar 

  31. Davids MS, Chatterjee A, Ravelo A, et al. Cost-effectiveness of a 12-month fixed duration of venetoclax in combination with obinutuzumab in first-line chronic lymphocytic leukemia in the United States [abstract no. 4741]. Blood. 2019;134(Suppl. 1).

  32. Souers AJ, Leverson JD, Boghaert ER, et al. ABT-199, a potent and selective BCL-2 inhibitor, achieves antitumor activity while sparing platelets. Nat Med. 2013;19(2):202–8.

    Article  CAS  Google Scholar 

  33. Ackler S, Oleksijew A, Chen J, et al. Clearance of systemic hematologic tumors by venetoclax (Abt-199) and navitoclax. Pharmacol Res Perspect. 2015;3(5):e00178.

    Article  Google Scholar 

  34. Cao Y, Yang G, Hunter ZR, et al. The BCL2 antagonist ABT-199 triggers apoptosis, and augments ibrutinib and idelalisib mediated cytotoxicity in CXCR4(Wild-type) and CXCR4(WHIM) mutated Waldenstrom macroglobulinaemia cells. Br J Haematol. 2015;170(1):134–8.

    Article  CAS  Google Scholar 

  35. Peirs S, Matthijssens F, Goossens S, et al. ABT-199 mediated inhibition of BCL-2 as a novel therapeutic strategy in T-cell acute lymphoblastic leukemia. Blood. 2014;124(25):3738–47.

    Article  CAS  Google Scholar 

  36. Vogler M, Dinsdale D, Dyer MJS, et al. ABT-199 selectively inhibits BCL2 but not BCL2L1 and efficiently induces apoptosis of chronic lymphocytic leukaemic cells but not platelets. Br J Haematol. 2013;163(1):139–42.

    Article  CAS  Google Scholar 

  37. Vandenberg CJ, Cory S. ABT-199, a new Bcl-2-specific BH3 mimetic, has in vivo efficacy against aggressive Myc-driven mouse lymphomas without provoking thrombocytopenia. Blood. 2013;121(12):2285–8.

    Article  CAS  Google Scholar 

  38. Touzeau C, Dousset C, Le Gouill S, et al. The Bcl-2 specific BH3 mimetic ABT-199: a promising targeted therapy for t(11;14) multiple myeloma. Leukemia. 2014;28(1):210–2.

    Article  CAS  Google Scholar 

  39. Phillips DC, Xiao Y, Lam LT, et al. Loss in MCL-1 function sensitizes non-Hodgkin’s lymphoma cell lines to the BCL-2-selective inhibitor venetoclax (ABT-199). Blood Cancer J. 2015;5:e368.

    Article  CAS  Google Scholar 

  40. Tausch E, Close W, Dolnik A, et al. Venetoclax resistance and acquired BCL2 mutations in chronic lymphocytic leukemia. Haematologica. 2019;104(9):e434–7.

    Article  CAS  Google Scholar 

  41. Freise KJ, Dunbar M, Jones AK, et al. Venetoclax does not prolong the QT interval in patients with hematological malignancies: an exposure-response analysis. Cancer Chemother Pharmacol. 2016;78(4):847–53.

    Article  CAS  Google Scholar 

  42. Salem AH, Agarwal SK, Dunbar M, et al. Effect of low- and high-fat meals on the pharmacokinetics of venetoclax, a selective first-in-class BCL-2 Inhibitor. J Clin Pharmacol. 2016;56(11):1355–61.

    Article  CAS  Google Scholar 

  43. Reda G, Cassin R, Dovrtelova G, et al. Venetoclax penetrates in cerebrospinal fluid and may be effective in CLL with central nervous system involvement. Haematologica. 2019;104(5):e222–3.

    Article  CAS  Google Scholar 

  44. Jones AK, Freise KJ, Agarwal SK, et al. Clinical predictors of venetoclax pharmacokinetics in chronic lymphocytic leukemia and non-Hodgkin’s lymphoma patients: a pooled population pharmacokinetic analysis. AAPS J. 2016;18(5):1192–202.

    Article  CAS  Google Scholar 

  45. Salem AH, Dave N, Marbury T, et al. Pharamcokinetics of the BCL-2 inhibitor venetoclax in subjects with hepatic impairment. Clin Pharmacokinet. 2019;58(8):1091–100.

    Article  CAS  Google Scholar 

  46. Salem AH, Hu B, Freise KJ, et al. Evaluation of the pharmacokinetic interaction between venetoclax, a selective BCL-2 inhibitor, and warfarin in healthy volunteers. Clin Drug Investig. 2017;37:303–9.

    Article  CAS  Google Scholar 

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Acknowledgements

During the peer review process, the manufacturer of venetoclax was also offered an opportunity to review this article. Changes resulting from comments received were made on the basis of scientific and editorial merit.

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    Hannah A. Blair

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Correspondence to Hannah A. Blair.

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The preparation of this review was not supported by any external funding.

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H. A. Blair is a salaried employee of Adis International Ltd/Springer Nature, and declares no relevant conflicts of interest. All authors contributed to the review and are responsible for the article content.

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Additional information

Enhanced material for this Adis Drug Evaluation can be found at https://doi.org/10.6084/m9.figshare.13146479.

The manuscript was reviewed by: M. J. S. Dyer, The Ernest and Helen Scott Haematological Research Institute, University of Leicester, Leicester, UK; S. Opat, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia; T. Robak, Department of Hematology, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland.

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Blair, H.A. Venetoclax: A Review in Previously Untreated Chronic Lymphocytic Leukaemia. Drugs 80, 1973–1980 (2020). https://doi.org/10.1007/s40265-020-01433-6

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