There are many medicines that can be given as an oral (by mouth) therapy for lymphoma and chronic lymphocytic leukaemia.
Overview of oral therapies in lymphoma (& CLL)
Lymphoma and chronic lymphocytic lymphoma (CLL) treatment can be a combination of anti-cancer medicines. They have been usually given into the vein (intravenously) and usually involve a combination of medicines including an antibody therapy and chemotherapy (immunochemotherapy).
This often involves administration of the treatment at a hospital or at a specialist cancer centre. However, there have been many developments in cancer for the treatment of lymphoma and CLL that can be taken by mouth in tablet form. These are known as oral therapies.
What are oral therapies?
Oral lymphoma therapies can be chemotherapy medicines, targeted therapies, and immunotherapies. They can be taken by mouth as a tablet, capsule, or as a liquid. The drug is absorbed into the bloodstream and carried around like intravenous drugs.
Oral therapies can be just as effective as intravenous options and they also have some different side effects. There are many factors relating to the subtype of lymphoma and the patient’s medical situation that must be balanced to choose the best treatment of the lymphoma. Therefore, the choice is best made in discussion with the specialist.
When are oral therapies used?
Most oral medicines used to treat lymphoma and CLL are immunotherapy agents or targeted therapies. Targeted therapies are directed against specific enzymes needed for the lymphoma to grow whereas standard chemotherapy medicines are directed against rapidly dividing cells whether they are lymphoma or other normal cells within the human body.
As chemotherapy medicines do not distinguish between lymphoma cells and normal healthy cells they inadvertently damage normal healthy cells leading to side effects such as lowered blood counts, hair loss, mouth sores, nausea, vomiting and diarrhoea whereas targeted therapies usually affect fewer normal healthy cells resulting in fewer of these types of serious side effects.
Starting an oral therapy treatment
Before patients commence treatment at home:
- The doctor will prescribe the treatment
- The pharmacist will dispense the medication for the patient
- An appointment will be scheduled to discuss the treatment and side effects that may occur
The nurse or pharmacist will explain in detail how to take the medications and this will include the dosage and how often it needs to be taken. Instructions will be given on the safe handling and storage of the medications. All the side effects of the treatment will be discussed, and written information will be given to the patient.
Things to know about taking oral therapies
Oral cancer therapies can be a convenient option for patients as they can be taken at home, however there are a few factors to consider:
- Patients are responsible for ensuring that they take their medicine, therefore there may be an increased risk of medication errors such as forgetting to take medication
on certain days or taking the incorrect dose which can compromise the effectiveness of the medicine.
- It is critical that patients take all medications as prescribed to maximise the effectiveness of the treatment and to minimise any side effects. Since keeping track of all the medications can be complicated, speak to the specialist team about how to keep on track. A variety of tools may be helpful including recording medication in a diary or creating online reminders in apps or on a smartphone
- Patients may feel less connected to their specialist team than they would if they were receiving intravenous medicines because they visit the hospital or specialist cancer centre less frequently. However, taking oral medicines at home may be beneficial for patients who must travel a long distance to their hospital in terms of time and money spent on travel.
- Side effects may also go unnoticed or unreported to the specialist team and patents may be uncertain how to manage side effects at home. Therefore, it is important to educate patients and their carers on these important areas. Many of the side effects of oral medications can be alleviated by supportive care so patients should carefully track all side effects of their treatment and report them to the specialist team when they happen, so they receive the best care.
Precautions when taking oral therapy at home
Commencing treatment at home:
- Oral therapies should never be touched with bare hands. May cause irritation
- Wash hands well with soap and water after handling medications
- Wear gloves when changing clothing or bedsheets soiled with vomit or diarrhoea
- Store tablets as instructed by pharmacist
- Store tablets safely away from children and pets
- Take oral therapy exactly as prescribed
- Carry a list of all current medications
- Plan for travel, refills, and weekends
- If you feel unwell at any time contact your healthcare team
- Inform any other healthcare providers about oral anti-cancer drugs
- Return all unused drugs to pharmacy for safe disposal
Types of oral therapy
TGA approved (the TGA is the Therapeutic Goods Authority in Australia) oral cancer therapies are medicines that inhibit the growth and promote the death of lymphoma cells. Some immune therapies stimulate the patient’s immune system to recognise the lymphoma cells and encourage the destruction of these cells. There are several classes of these medicines listed below:
Oral chemotherapy used in lymphoma
How it works
Most common side effects
|Cyclophosphamide||Chemotherapy: Alkylating agent||Chemically modifies DNA to cause death of growing cells||CLL HL NHL||Low blood counts Infection Nausea & vomiting Loss of appetite|
|Etoposide||Chemotherapy: Topoisomerase II inhibitor||Interferes with topoisomerase enzymes that control manipulation of the structure of DNA necessary for replication||CTCL NHL||Nausea & vomiting Loss of appetite Diarrhoea Fatigue|
|Chlorambucil||Chemotherapy: Alkylating agent||Chemically modifies DNA to cause death of growing cells||CLL FL HL NHL||Low blood counts Infection Nausea & vomiting Diarrhoea|
Other oral treatments used in lymphoma
How it works
Most common side effects
|Ibrutinib||BTK Inhibitor||Inhibits an enzyme involved in B cell receptor signalling needed for lymphoma cell survival and growth||CLL MCL||Heart rhythm problems Bleeding problems High blood pressure · Infections|
|Acalabrutinib||BTK inhibitor||Inhibits an enzyme involved in B cell receptor signalling needed for lymphoma cell survival and growth||CLL MCL||Headache Diarrhoea Weight gain|
|Zanubrutinib||BTK inhibitor||Inhibits an enzyme involved in B cell receptor signalling needed for lymphoma cell survival and growth||CLL MCL WM||Low blood counts Rash Diarrhoea|
|Idelalisib||P13K Inhibitor||Inhibits an enzyme involved in B cell receptor signalling needed for lymphoma cell survival and growth||CLL FL||Diarrhoea Liver problems Lung problems Infection|
|Venetoclax||BCL2 Inhibitor||Targets proteins known to prevent lymphoma cells from dying||CLL||Nausea Diarrhoea Bleeding problems Infection|
|Lenalidomide||Immunomodulatory agent||Precise mechanism unknown. Thought to modulate the immune system.||Used in some NHLs||Skin rash Nausea Diarrhoea|
|Vorinostat||HDAC Inhibitor||Inhibits HDAC enzymes needed for expression of genes in DNA to inhibit lymphoma cell growth and division||CTCL||Loss of appetite Dry mouth Hair loss Infections|
|Panobinostat||HDAC Inhibitor||Inhibits HDAC enzymes needed for expression of genes in DNA to inhibit lymphoma cell growth and division||HL CTCL||High magnesium levels High bilirubin levels Nausea Infections|
|Bexarotene||Retinoid||Selectively binds and activates retinoid receptors resulting in expression of genes that control cell growth and replication||CTCL||Skin rash Nausea Low thyroid hormones levels Infections|