Q: My 75 years old father was diagnosed with chronic lymphocytic leukaemia (CLL) five years back. He was given pulse therapy of Chlorambucil (10mg) for two weeks with prednisone every month for eight months. Then it was stopped for a year. Again this medication was given to him for ten months and has now been discontinued. Now his WBC count is 120,000/mcl; lymphocytes - 90%, Neutrophils-10%, Platelets-225000 and Hb-11.5%. Now the doctor wants him to start having Rituximab with Bendamustine. Kindly advise whether Chlorambucil can be given again? What are success rate for rituximab and bendamustine?

A:Bendamustine, 4-[5-[Bis(2-chloroethyl)amino]-1-methylbenzimidazol-2-yl]butanoic acid, which has been used in Germany for more than 30 years, is the new drug on the anvil for the treatment of CLL. This drug has been compared with chlorambucil in a randomized trial. The overall survival and median progression-free survival rates were better than for chlorambucil. Also, for your information, bendamustine was approved by the US Food and Drug Administration (FDA) for the treatment of CLL. Currently, Bendamustine has been combined with rituximab in many studies on patients with relapsed CLL. In most of these studies patients receiving bendamustine and rituximab had better overall survival and disease free survival and in addition, the side effects of Grade 3/4 neutropenia and thrombocytopenia were minimal compared to the other therapies available.

Based on the above explanation, if cost is not the constraint, the Bendamustine & Rituximab combination appears better for him since he is a relapsed CLL. Other regimens are also available which can include fludarabine, etc; however, the decision should be taken in consultation with your treating hemato-oncologist. Chlorambucil alone in second relapse would probably be either less effective or in-effective in controlling the disease.

For statistical details about different drugs in CLL you can link to the following site:

http://asheducationbook.hematologylibrary.org/cgi/content/full/2009/1/440.

Hope this is helpful.