Nutrition and Supportive Care Considerations for Patients Receiving BTK inhibitor drugs

Nutrition and supportive care for patients on BTK inhibitor drugs is important to manage for patients with B-cell malignancies such as CLL (Chronic Lymphocytic Leukemia) and SLL (Small Lymphocytic Lymphoma). BTK inhibitor drugs are among the treatment options available for patients with these types of cancers. These oral targeted therapies may be administered outside of an infusion center but require more than just disease control for long-term management. Supportive care, including nutrition, hydration, physical activity, infection prevention, adherence to medication, monitoring of laboratory values and overall quality of life, is important to optimize for patients on BTK inhibitor drugs.

As with any long-term treatment, the patient’s nutritional and supportive care needs might change over time. Therefore, the healthcare professional managing the patient on long-term treatment with a BTK inhibitor must be aware of these changes and adjust the patient’s care as necessary.

Assessing Nutritional Status

Several factors can affect a person’s nutritional intake while they are receiving treatment for cancer. These can be caused by cancer itself or by the treatment. Recently lost weight, loss of appetite, poor intake of nutrients, poor intake of fluids, gastrointestinal problems, and decreased functional status are examples of nutritional risks in patients with cancer that can be identified by health care professionals. The nutritional needs of a person with cancer can change during their course of treatment.

There are many reasons why patients with cancer experience a decrease in food intake. The reasons for decreased food intake in patients with cancer can be caused by the cancer itself, by the treatment for cancer, by an infection, by other illness, and in many cases the reasons for decreased food intake can be reversed by the appropriate treatment for the underlying cause.

A patient with cancer and significant weight loss, poor intake or other indicators of poor nutrition may benefit from a referral to a registered dietitian or other qualified nutrition professional.

Maintaining Adequate Hydration

Hydration is an important element of care and patients need to be told to drink plenty of fluids to maintain proper hydration unless contraindicated (e.g. in a patient with heart failure or kidney failure). Patients can become dehydrated without knowing it, especially if they have diarrhea or vomiting, have a fever, or have a decreased oral intake. Patients should seek medical attention if they have any symptoms that may indicate dehydration.

In addition to the factors mentioned above, other factors that can increase the risk of dehydration in patients with CLL include diarrhea, vomiting, fever, decreased oral intake, and increased fluid losses. Patients and their families should be able to recognize the symptoms of dehydration and report them to the patient’s healthcare team as needed.

While there is general information provided to patients regarding how much fluid to drink on a daily basis, it is often better to explain the factors that affect a patient’s fluid balance. There are many factors that can affect a patient’s fluid status such as old age or comorbidities.

Food Intake and Dietary Considerations

No single diet is known to treat CLL or any other B-cell malignancies. It is advisable for patients with cancer to eat a normal, balanced diet to provide optimal nutrition to support their total health and well-being.

Eating small, frequent meals can help maintain energy needs when appetite has decreased. It is very important that these meals are nutrient dense, meaning that they contain a lot of calories and protein.

Nutritional supplements are not necessarily good for patients with cancer and so all vitamins, herbal products, etc. that a patient with cancer takes should be listed in their list of prescription and over-the-counter medications.

Drug Interactions and Food-Related Considerations

For the majority of BTK inhibitors, which are oral administered, a list of all products a patient is taking (including prescription and over-the-counter products as well as dietary supplements) before starting a new treatment should be provided to their healthcare team. This list should include a description of all of the patient’s current medications as well as any changes to their current treatment.

Interactions of BTK inhibitors with other drugs, in particular through their influence on the cytochrome P450 enzymes, exist for all approved drugs and have to be considered on a case-by-case basis. Food and drug interactions for each of the approved BTK inhibitors are described in detail in the prescribing information of each individual drug. Therefore, patients should not rely on general information for all BTK inhibitors but refer to the prescribing information of the specific BTK inhibitor they are on.

The patient should be given information on the specific administration of the BTK inhibitor they are on. The administration of the specific BTK inhibitor can include the time of day that it needs to be taken and what the patient should do if they miss a dose of the medication.

Prevention and Supportive Care

Infectious complications are a concern in patients with CLL due to the inherent immuno-compromised state of the patient and the additional immunosuppression from cancer and its treatment. A CLL patient with fever, chills, worsening cough or shortness of breath should report this to their healthcare team as soon as possible.

Vaccinations for patients with cancer are given on an individual basis and take into account the patients’ disease, treatment, immune status and current clinical guidelines. Live vaccines are given under the guidance of clinical staff as cancer treatment can affect the patient’s immune system and increase the risk of adverse effects.

Managing Fatigue and Physical Activity

It is very important to assess the causes of fatigue. Many of these are reversible. Fatigue is one of the more common symptoms reported by patients with cancer. This can be maintained during CLL treatment. Patients with CLL should, however, be advised that their strength, mobility and function can decline due to the disease or its treatment. Individual consideration should be given to the patient’s age, pre-treatment fitness, symptoms, blood count, disease and treatment-related complications. It is advisable to reduce activity for short period of time until it is determined what is causing the cytopenias, infection, fatigue, etc.

Monitoring Blood Counts and Other Laboratory Values

The supportive care for patients on BTK inhibitors includes monitoring of cytopenias like neutropenia, anemia or thrombocytopenia. Monitoring the complete blood count (CBC) is part of the supportive care for patients on BTK inhibitors.

Monitoring blood counts (CBC) is important for detecting significant changes to a patient’s blood during treatment with a BTK inhibitor. Monitoring other laboratory values such as liver function tests (LFTs) and others as required by the specific BTK inhibitor or patient’s medical history is also important. Explain the purpose of monitoring for the patient and explain how test results will be used to adjust their treatment.

Bleeding and Cardiovascular Considerations

Unusual bruising, prolonged bleeding, blood in the urine or stools can be serious concerns.

Review the patient’s other medications for the potential for additive effect on bleeding risk (i.e. concomitant anticoagulants/antiplatelets). Management of patients on BTK inhibitors for invasive procedures will vary on a case by case basis and should be managed according to the specific product’s prescribing information.

It is important to monitor for cardiac arrhythmias such as atrial fibrillation or atrial flutter, which have been associated with some of the BTK inhibitors and patients with pre-existing cardiac disease.

Supporting Quality of Life

Assess for and manage impact of cancer and treatment on functioning (physical, social, role, emotional) and monitor for changes in laboratory and disease related outcomes. Assess for impact of cancer on functioning during clinic visit (e.g. sleep, appetite, fatigue, physical activity, work, social activity, etc.).

A patient’s practical situation may affect their adherence to their medication. This can include factors that affect the timing of their medication, their ability to get to a pharmacy (and how far this is from their home), the cost of their medication, and whether they have any caregivers to support them with their treatment. Early identification of potential problems can allow for support to be given to the patient as required.

A Multidisciplinary Approach to Supportive Care

A team of healthcare professionals including hematologists, medical and radiation oncologists, nurses, dietitians, and pharmacists, and the patient’s primary care physician can all contribute to the patient’s care.

Supportive care and nutrition to treat patients who are on BTK inhibitor drugs for their CLL are ideally given on an individual basis as part of their overall treatment. Any new or worsening symptoms need to be reported to the doctor.

Medical Disclaimer: The information provided in this article is intended for educational purposes only and should not be interpreted as medical advice, clinical guidelines, or a recommendation for any specific treatment.