Treating Cold Agglutinin Disease With Anti–B-Cell Therapy

Clinicians comment on their approaches when treating patients with cold agglutinin disease with an anti–B-cell therapy.

Neil Minkoff, MD: Let me ask my clinical colleagues here, is there a difference or an advantage in the dosing of any of these regimens over the others? Or are there any advantages to particular patient populations? I guess I’m trying to help my payer colleagues or others as they come into this try to say, “Well, should we be looking for this?” Or is it just too rare, and looking for these generalities is not helpful? You can tell me I’m wrong. I don’t care.

Jeremy Lorber, MD: In terms of dosing regimens, all are reasonable for the therapies we’ve discussed, mainly because, for example the rituximab regimens are given just every 4 weeks, and more importantly it’s given for a finite duration; it’s not given for years. Most patients will receive roughly 4 months or so of therapy and then be done hopefully for a long time, and most patients can tolerate that, versus some other diseases we treat, patients are getting therapies indefinitely. It can go on for years and can be a burden on the patient in terms of cost and visits to the doctor.

Mihir Raval, MD, MPH: I agree with what Dr Lorber just pointed out. Sometimes, when you do use chemotherapy along with rituximab, that does require some more involvement from the patient side because the adverse effect profile is a little bit more. They do get cytopenic, they may have a risk of infection from using bendamustine. Thus, those may require some extra laboratory work or visits to make sure that they don’t have any major adverse effect that requires hospitalization for those patients.

Neil Minkoff, MD: Well, that kind of raises a question I probably should’ve asked a while ago, which is, what is the standard of care in terms of how often patients are seen? Are they seen on a regular basis, say semiannually or quarterly, to keep them on an even keel, or is it mostly episodic-based care?

Mihir Raval, MD, MPH: I would say it’s more dynamic. When a patient starts out initially with the diagnosis, depending on the severity of their anemia, their frequency of visit to the clinic is going to be more. Once we make a decision that no, their anemia is stable now with the treatment that I’ve provided, then gradually I have them come in every 3 months for labs. If their titer for cold agglutinin is not changing, if their anemia is not worsening, then I may see them every 6 months. But they are coming in for labs every 3 months, while educating the patient that, “Hey, if you start feeling more tired, you start feeling more fatigue, you start feeling more weak, then give us a call. Don’t wait for your 3-month lab appointment. You can come in any time to have your labs done.”

Neil Minkoff, MD: Anything to add to that, Dr Lorber, or similar?

Jeremy Lorber, MD: I’m in agreement. At the beginning, there is no pattern, there is no set interval. It depends how the patient’s doing, and after a while if they’re doing well and they’re not on any specific treatment, it’s really patient-directed. Because again, the main point of treatment in this disease is to help patients’ symptoms. We’re not really treating a number. If a patient is feeling well, then they probably don’t need to come in very much, but if they start feeling effects of their CAD [cold agglutinin disease], that would be a reason to get checked out.

Transcript edited for clarity.

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