I am treating a patient with
Dose Modification Decision Charts
CLL
*GCSF can be considered in select patients depending on regimen
CLL DOSE MODIFICATION DURING RAMP UP WITH CYP3A INHIBITORS
Week 1
10mg
Moderate CYP3A Inhibitors include but are not limited to:
Ciprofloxacin
Erythromycin
Diltiazem
Fluconazole
Dronedarone
Verapamil
Week 2
20mg
Week 3
50mg
Week 4
100mg
Week 5
200mg
CLL Dosing with Strong CYP3A Inhibitors - Contraindicated during ramp up of venetoclax
Posaconazole with venetoclax - Dose reduce venetoclax to 70mg Steady Daily Dose
Other Strong CYP3A Inhibitors - Dose reduce venetoclax to 100mg Steady Daily Dose
In some cases, venetoclax treatment can be paused, CYP3A inhibitor is given for course of treatment, then venetoclax can be resumed 2-3 days after discontinuation of CYP3A inhibitor
Strong CYP3A Inhibitors include but are not limited to:
Clarithromycin
Lopinavir
Indinavir
Posaconazole
Itraconazole
Ritonavir
Ketoconazole
Voriconazole
DOSE REDUCTIONS FOR TLS AND OTHER TOXICITIES
Dose at Interruption
Restart Dose
400mg
300mg
300mg
200mg
200mg
100mg
100mg
50mg
50mg
20mg
20mg
10mg
*Any dose interruption lasting more than 1 week during ramp up phase, or more than 2 weeks after completion of ramp up, reassess for TLS to determine if reinitiation with reduced dose is warranted
*Consider discontinuing venetoclax in patients who require dose reductions to < 100mg for more than 2 weeks
AML
*For Grade 3-4 non-hematologic toxicities, interrupt venetoclax if toxicity not resolved with supportive care. Upon resolution to Grade 1 or baseline, resume venetoclax at same dose.
*Bone marrow assessment recommended at the end of Cycle 1 to measure response. After achieving remission, treatment should be delayed until counts recover
CLL

*GCSF can be considered in select patients depending on regimen
CLL DOSE MODIFICATION DURING RAMP UP WITH CYP3A INHIBITORS | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Week 1 | 10mg |
Moderate CYP3A Inhibitors include but are not limited to:
|
|||||||||
Week 2 | 20mg | ||||||||||
Week 3 | 50mg | ||||||||||
Week 4 | 100mg | ||||||||||
Week 5 | 200mg | ||||||||||
CLL Dosing with Strong CYP3A Inhibitors - Contraindicated during ramp up of venetoclax | |||||||||||
Posaconazole with venetoclax - Dose reduce venetoclax to 70mg Steady Daily Dose | |||||||||||
Other Strong CYP3A Inhibitors - Dose reduce venetoclax to 100mg Steady Daily Dose | |||||||||||
In some cases, venetoclax treatment can be paused, CYP3A inhibitor is given for course of treatment, then venetoclax can be resumed 2-3 days after discontinuation of CYP3A inhibitor | |||||||||||
Strong CYP3A Inhibitors include but are not limited to:
|
|||||||||||
DOSE REDUCTIONS FOR TLS AND OTHER TOXICITIES | |||||||||||
Dose at Interruption | Restart Dose | ||||||||||
400mg | 300mg | ||||||||||
300mg | 200mg | ||||||||||
200mg | 100mg | ||||||||||
100mg | 50mg | ||||||||||
50mg | 20mg | ||||||||||
20mg | 10mg | ||||||||||
*Any dose interruption lasting more than 1 week during ramp up phase, or more than 2 weeks after completion of ramp up, reassess for TLS to determine if reinitiation with reduced dose is warranted | |||||||||||
*Consider discontinuing venetoclax in patients who require dose reductions to < 100mg for more than 2 weeks |
AML

*For Grade 3-4 non-hematologic toxicities, interrupt venetoclax if toxicity not resolved with supportive care. Upon resolution to Grade 1 or baseline, resume venetoclax at same dose.
*Bone marrow assessment recommended at the end of Cycle 1 to measure response. After achieving remission, treatment should be delayed until counts recover