Supportive or Palliative Care for Chronic Lymphocytic Leukemia (CLL)

If you have chronic lymphocytic leukemia (CLL), supportive treatments could help prevent or relieve some of your symptoms. You might also hear this called palliative care.

Supportive care for CLL is aimed at helping with symptoms or other problems related to the leukemia and its treatment. It isn’t meant to treat the CLL itself. For example, some people with CLL have infections or low blood cell counts that can be treated with supportive care.

When is supportive care used for CLL?

Treating the CLL directly (with targeted drugs, chemotherapy, and/or immunotherapy) may help with some of the problems related to CLL over time. But supportive care treatments are often an important part of a person’s overall treatment plan. These two types of treatments are often used at the same time.

Treatments to help prevent infections in people with CLL

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

• Lowering your risk of CMV infection: You might be given an antiviral drug like acyclovir or valacyclovir to help lower your risk of CMV infection.
• Preventing Pneumocystis pneumonia: 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.
• Keeping dormant viruses under control: Some drugs used to treat CLL can also cause dormant viruses to become active. 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 your virus levels. You might be given drugs to help keep these viruses under control.
• Treating active infections: Antibiotics, antivirals, 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.

Your antibody levels can be checked with a blood test. If they're low, you might get antibodies from a donor to raise your levels and help prevent infections. These are injected into your vein (IV). The donated antibodies are called intravenous immunoglobulin (IVIG).

Most people with CLL don’t usually need IVIG. If it is needed (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 aren’t 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
• Pneumococcal vaccine (to help prevent pneumonia)
• 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 on vaccines, see Vaccinations and Flu Shots for People with Cancer.

Treatments for low blood counts in people with CLL

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

Low red blood cell counts (anemia)

Having a low red blood cell 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.

Low platelet counts

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

Low blood cell counts caused by autoimmunity

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

Immune thrombocytopenia (ITP)

When antibodies cause low numbers of platelets, it’s called immune thrombocytopenia (ITP).

Before diagnosing ITP, the bone marrow is often checked to make sure something else isn’t causing the low platelet counts.

In ITP, giving platelet transfusions doesn’t usually help increase platelet counts. This is because the antibodies just destroy the new platelets, too. ITP 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, because after the antibodies stick to the platelets, they're destroyed in the spleen. To learn more about removing the spleen, see Surgery for CLL.

Autoimmune hemolytic anemia (AIHA)

When antibodies cause low red blood cell counts, it's called autoimmune hemolytic anemia (AIHA). This 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 also be helpful.

Treating very high white blood cell counts (leukapheresis) in people with CLL

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.

How leukapheresis works

For 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 placed near your neck or under your collar bone instead of using IV lines in your 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.