The Decision For Nonstandard Biologic Therapy Versus Additional Purine Analog Therapy

As mentioned above, both purine analogs are quite effective in HCL, even as second or even third courses. In fact, it is often unclear who should receive a repeat course of purine analog and who should receive salvage therapy. This decision depends somewhat on the toxicity of cladribine and pentostatin. Either agent has been reported to deplete resting T cells, particularly CD4+ lymphocytes, for up to 4 years.2728 The length of prior response to the last course of purine analog is often used to decide whether to repeat the course. If the last response was brief, a repeat course of purine analog might risk cumulative overlapping damage to CD4+ lymphocyte populations. Furthermore, as both the likelihood and the duration of complete remission (CR) decline with repeated courses of purine analogs, the chance of benefit is lower in patients with shortlived prior response. In general, most physicians will use a repeat course of purine analog if the last response was greater than 2 years, particularly if only one prior course of purine analog was given. Patients with less than 1 year of response to prior cladribine or pento-statin should be offered other therapy. Patients having 1-2-year response to the last course of purine analog may be appropriate for nonstandard therapy, and this may also be the case for patients with a 2-4-year response to a second or later course of purine analog.

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