Venetoclax and Ibrutinib or Acalabrutinib in Treating Patients with High-Risk Chronic Lymphocytic Leukemia

Inclusion Criteria

• Patients must have a diagnosis of CLL/CLL and EITHER have high-risk cytogenetic features or molecular features, defined as: del(17p), mutated TP53, complex metaphase karyotype (defined as >= 3 unrelated chromosomal abnormalities, present in at least 2 metaphases on conventional, stimulated cytogenetic analysis) * Note: some patients treated with ibrutinib or acalabrutinib may no longer have detectable fluorescence in situ hybridization (FISH), karyotypic or molecular abnormalities after 12 months of therapy. These patients will be eligible if they fulfill the above criteria on a bone marrow biopsy or peripheral blood specimen taken either prior to starting ibrutinib or acalabrutinib, provided they did not receive treatment for their CLL between the date of the lab test and starting ibrutinib or acalabrutinib or at some time during their ibrutinib therapy and analyzed at a Clinical Laboratory Improvement Act (CLIA)-accredited laboratory
• Patients must have received at least 12 months of ibrutinib or acalabrutinib therapy and have measurable CLL by at least one of the following: * Absolute monoclonal lymphocyte count > 4000/microL; OR * Measurable lymph nodes with at least one node > 1.5 cm in diameter on computed tomography (CT); OR * Bone marrow with >= 30% lymphocytes on aspirate differential OR * Detectable CLL cells using a standardized flow cytometry assay for minimal residual disease
• Age 18 years or older
• Eastern Cooperative Oncology Group (ECOG) performance status =< 2
• Serum bilirubin =< 1.5 x upper limit of normal (ULN) or =< 3 x ULN for patients with Gilbert’s disease
• Serum creatinine clearance of >= 50 ml/min (calculated or measured)
• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =< 3.0 x ULN, unless clearly due to disease involvement
• Platelet count of greater than 50,000/ul, with no platelet transfusion in prior 2 weeks
• Absolute neutrophil count (ANC) >= 1000/ul in the absence of growth factor support unless due to compromised bone marrow production from CLL, indicated by >= 80% CLL in marrow
• Hemoglobin >= 8 mg/dL
• International normalized ratio (INR) < 1.5
• Absence of uncontrolled cardiac arrhythmia
• Echocardiogram demonstrating left ventricular ejection fraction (LVEF) >= 35%
• New York Heart Association (NYHA) functional class =< 2
• Ability to provide informed consent and adhere to the required follow-up
• Women of childbearing potential must have a negative serum or urine beta human chorionic gonadotropin (beta-human chorionic gonadotropin [hCG]) pregnancy test result within 7 days prior to the first dose of study drugs and must agree to use both a highly effective method of birth control (e.g., implants, injectables, combined oral contraceptives, some intrauterine devices [IUDs], complete abstinence, or sterilized partner) and a barrier method (e.g., condoms, vaginal ring, sponge, etc.) during the period of therapy and for 30 days after the last dose of study drug. Women of non- childbearing potential are those who are postmenopausal (defined as absence of menses for >= 1 year) or who have had a bilateral tubal ligation or hysterectomy. Men who have partners of childbearing potential must agree to use effective contraception, defined above, during the study and for 30 days following the last dose of study drug * Complete abstinence is a highly effective method only if defined as refraining from heterosexual intercourse during the entire period of risk associated with the study treatments. The reliability of sexual abstinence needs to be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the subject
• Patients or their legally authorized representative must provide written informed consent

Exclusion Criteria

• Richter transformation
• Active malignancy requiring systemic therapy, other than CLL, with the exception of: adequately treated in situ carcinoma of the cervix uteri; adequately treated basal cell carcinoma or localized squamous cell carcinoma of the skin; previous malignancy confined and surgically resected (or treated with other modalities) with curative intent
• Major surgery, radiotherapy, chemotherapy, biologic therapy, immunotherapy, experimental therapy within 3 weeks prior to the first dose of the study drug
• Grade 3 or 4 hemorrhage within the past 3 weeks
• Uncontrolled active infections (viral, bacterial, and fungal)
• Females who are pregnant or lactating
• Known positive serology for human immunodeficiency virus (HIV)
• Active hepatitis B infection (defined as the presence of detectable hepatitis B virus [HBV] deoxyribonucleic acid [DNA] or hemoglobin E [HBe] antigen). Patients who are hepatitis B surface antigen (HBsAg) or hepatitis B core antibody (HBcAb) positive are eligible, provided HBV DNA is negative. These patients will have monthly monitoring of HBV DNA for the duration of the study, if clinically indicated. Please note that patients who have received intravenous immunoglobulin (IVIG) may have false positive HBcAb results. In such patients, if HBV DNA and HBsAg are negative, serial HBV DNA monitoring is not necessary
• Active hepatitis C, defined by the detection of hepatitis C ribonucleic acid (RNA) in plasma by polymerase chain reaction (PCR)
• Active, uncontrolled autoimmune phenomenon (autoimmune hemolytic anemia or immune thrombocytopenia) requiring steroid therapy > 20 mg prednisone daily or equivalent, within 7 days of starting venetoclax
• Received other investigational therapeutic agent for CLL/SLL within 21 days of starting venetoclax
• Concurrent use of warfarin
• Received strong CYP3A inhibitors or strong CYP3A inducers within 7 days of starting venetoclax
• Consuming grapefruit, grapefruit products, Seville oranges, or star fruit within 7 days of starting venetoclax
• Prior treatment with venetoclax or other Bcl-2 inhibitor
• Malabsorption syndrome or other condition that precludes enteral route of administration