This is a true story. The patient and his family have allowed us to publish it without his name, in the hope that it helps other patients and families.
About seven years ago, a man in Tehran, then nearly 65, was told he had blood cancer: chronic lymphocytic leukaemia, or CLL. The word "cancer" is hard for anyone to hear, but he felt well. He had always been a sporty man: he walked every day, looked after himself, and life went on as usual. CLL often progresses slowly [10], and he decided to get to know his disease well.
Year after year, the white cell count on his lab reports grew, until it passed 100,000, far above normal. One doctor, then another, and over those years about ten doctors in all, told him he should start chemotherapy.
But he was not one to give in without asking questions. He read, asked and searched, and learned that in CLL, as long as the disease is quiet and certain signs have not appeared, waiting with regular blood tests can be the right decision [1]. So each time his decision was the same: wait and keep watching. He kept up his blood tests and got on with his life. Seven years went by like this: seven years of normal life, without a single day of chemotherapy.
In the spring of 2025, the calm of those seven years fell apart within a few weeks. A medicine that an eye doctor had prescribed for him was taken in too high a dose. A tiredness like no other set in; he became so weak that even simple things were hard. And the disease that had been quiet for seven years seemed to wake up: his blood count fell, his platelets dropped and his white cell count climbed faster than ever.
He ended up in hospital. The oxygen in his blood had fallen dangerously low, and he spent two weeks there on strong antibiotics. Then a new problem appeared: he could no longer swallow food and water properly. Any mouthful or sip could go into his lungs instead of his stomach and infect them, an infection doctors call "aspiration pneumonia" [11].
One day he ate a few apricots, and those few apricots were enough to bring the pneumonia back and put him in hospital again. This time a speech therapist came to help too: swallowing exercises, along with gentle electrical pulses on his neck. About twelve days later he walked out of the hospital on his own two feet, without oxygen, and hope came back to life.
But the calm did not last. For two days in a row he had nosebleeds. At night, exhaustion and waking again and again kept him from sleeping. And the infections kept coming back, each time more stubborn than before, and each time the antibiotics worked less well.
For three whole months, his food went through a tube that ran from his nose to his stomach: about a litre of liquid nutrition a day. He had become so weak that he could barely take a step. His doctors began to talk about a "PEG": a tube placed through the wall of the abdomen directly into the stomach in a small procedure, which would mean he might be fed through a tube for months, or even years.
During these months, his doctors had also started him on a targeted tablet called ibrutinib. His white cell count came down a little, but he did not get better.
In late summer 2025, three months into these hard days, his family took him, just as he was, to Dr. Mohammadreza Dabiri, an adult haematology–oncology subspecialist. The first battle was against the infection. The last time it flared, even meropenem failed, and only another antibiotic, piperacillin–tazobactam, could bring it under control. And this time, the infection did not come back.
With his lungs finally at peace, his body slowly came back to life. He was able to swallow again, and the day came when the feeding tube was taken out; the abdominal tube was never needed. The man who for months could barely take a step got moving again: a few steps at first, then more and more.
But the root of the problem was still there: the leukaemia itself. After about four months, ibrutinib had not brought it under control. In the autumn of 2025, Dr. Dabiri made a decision that changed the course of the story: stop ibrutinib and start a tablet called venetoclax, together with monthly infusions of rituximab.
Venetoclax is a powerful medicine that has to be started carefully [5], so the treatment began in hospital. The dose started low and went up one step each week for five weeks. Intravenous fluids, a medicine to lower the uric acid in his blood and frequent blood tests watched over his kidneys [5]. He was given antibiotics too, so that the infection would not come back.
And then came a change few expected. Just two weeks later, his white cell count, which a few months earlier had reached about 300,000, was down to about 3,000: a normal number, for a man who for years had been used to seeing six-digit numbers on his lab reports. Since that day, with small ups and downs, it has stayed within or close to the normal range.
Month by month, he grew stronger. Today, about a year later, he is once again the sporty man he always was: he walks and exercises for an hour every day, eats on his own and lives a completely normal life. Anyone who meets him today would never guess that a year ago he was fed through a tube and could barely take a step. In the hardest days of his illness, when one antibiotic after another was failing and there was talk of a tube in his abdomen, hardly anyone could have believed this day would come.
His rituximab infusions finished months ago. He will take venetoclax for one more year, and then, as planned, it will stop. His blood tests are done regularly, and his white cell count is about 7,000.
His story was full of moments when it would have been easy to lose hope. But it shows that today's treatments for blood cancer can change the course of a life, even when everything seems hopeless.
What does this story tell us?
A high white cell count alone is not a reason for treatment
In CLL, treatment is needed when the disease becomes active, not just because the number is high [1]. Waiting, with regular blood tests and examinations, is a treatment decision in itself, but make it with a haematologist–oncologist.
Take the signs of active disease seriously
Anaemia, a low platelet count, enlarging lymph nodes or spleen, weight loss, fever, night sweats or severe tiredness mean you should see a haematologist–oncologist soon [1].
Take infections seriously in CLL
CLL weakens the immune system over time. Have the recommended vaccines, such as pneumococcal, shingles and flu vaccines, as advised by your doctor [1], and see a doctor promptly if you develop a fever or a new cough. Preventing infection
Most patients today do not need chemotherapy
When CLL needs treatment, targeted medicines are the first choice for most patients [1]. If you are offered only chemotherapy, ask why. Chemotherapy or targeted tablets in CLL?
If one treatment is not enough, there is another way
Tablets such as ibrutinib work well for many people with CLL [9]. If they do not control the disease, venetoclax-based treatment works in most patients [1, 8].
Check every medicine with your haematologist–oncologist
Tell every doctor you see that you have CLL, and discuss any new medicine with your haematologist–oncologist as well. Some medicines, and even some fruits such as grapefruit, interact with CLL medicines [5].
This is the story of one patient. Not every patient responds this quickly or this well, and the choice of treatment depends on test results, other illnesses, other medicines and the patient's own wishes [1].
If your doctor thinks you need treatment, ask which sign of the disease shows this and what the options are. Make the decision together, and if you are unsure, get a second opinion from a haematologist–oncologist. Do not start, stop or change treatment on your own.
Frequently asked questions
Is it right to wait in CLL?
Yes, as long as the disease is quiet. International guidelines say that treatment should start only once the disease has become "active" [1, 2]: for example, when anaemia or a low platelet count develops because the disease is progressing, the lymph nodes or spleen become very large or keep growing, the lymphocytes rise very quickly (for example, doubling in less than 6 months), or weight loss, fever, night sweats or severe tiredness appear because of the disease itself [1]. A high white cell count on its own is not one of these reasons. In several studies, starting treatment earlier in people without symptoms did not help them live longer, even with the newer medicines [1]. Waiting is right only with regular blood tests and examinations, and with the advice of a haematologist–oncologist.
What is aspiration pneumonia?
When food, liquid or saliva goes into the airways and lungs instead of being swallowed, the lungs become infected. Older age, swallowing problems and being in hospital all raise the risk [11]. In CLL the immune system weakens over time [1], and infection is one of the most serious complications of the disease [10].
How do venetoclax and rituximab work?
CLL cells depend on a protein called BCL-2, which blocks the cell's natural death, to stay alive; venetoclax binds to this protein and reopens the path to death for the cancer cell [5]. Rituximab is an antibody that attaches to a marker called CD20 on the surface of B lymphocytes and causes them to be destroyed [6]. In this combination, rituximab is given once a month, 6 times in total, and venetoclax is taken for 2 years in total and then stopped [3, 5]. The European guideline recommends venetoclax-based treatment for people whose disease has progressed on medicines such as ibrutinib [1].
Why was the treatment started in hospital and at a low dose?
Venetoclax can kill cancer cells so quickly that the substances released from them, such as potassium and uric acid, build up in the blood and damage the kidneys; this is called "tumour lysis syndrome" [5]. The risk is higher in people with very high lymphocyte counts. That is why the dose is raised gradually over 5 weeks and, in high-risk patients, the first doses are given in hospital with intravenous fluids, a medicine to lower uric acid and frequent blood tests [5].
What are the side effects of venetoclax?
The main risk in the first weeks is tumour lysis syndrome [5]. A severe drop in white blood cells (neutropenia) has been seen in more than half of patients with CLL and raises the risk of infection, which is why blood counts are checked regularly [5]. Do not eat grapefruit, Seville oranges or starfruit during treatment [5]. Read more: Venetoclax
Is rituximab the same as chemotherapy?
Has this patient been cured?
His disease is now under control and he lives a normal life. CLL usually does not go away completely, but it often progresses slowly and can be controlled for years [10]. In the MURANO study, in people whose CLL had come back after earlier treatment, these same two years of treatment kept the disease under control for a median of about four and a half years, compared with about one and a half years with chemotherapy plus rituximab [4]. If the disease ever comes back, there are other effective treatments [1], and in the same study, repeating the same combination worked again in most of the people who received it a second time [4]. Read more: What does remission mean?
Case report for doctors
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A 72-year-old man in Tehran with CLL, untreated in Rai stage 0 for about 7 years. In spring 2025, after an overdose of a medicine prescribed for an eye condition, he developed a rapid general decline, cytopenias, dysphagia and recurrent aspiration pneumonia with a dwindling response to antibiotics, and was fed through an NG tube for about 3 months. Once the infection was controlled, swallowing and walking returned and the NG tube was removed (PEG was not needed). Because of an inadequate disease response after about 4 months of ibrutinib, treatment was switched to venetoclax + rituximab (MURANO schedule); the WBC normalised within 2 weeks, and a year later he leads a completely normal, active life.
| Time | Clinical status | Tests | Treatment |
|---|---|---|---|
| About 7 years, to spring 2025 | Asymptomatic Rai stage 0 CLL; normal daily activity | Progressive lymphocytosis; WBC above 100 × 10⁹/L | Active surveillance; the patient declined the chemotherapy he was offered |
| Spring 2025 | Overdose of a medicine prescribed for an eye condition; severe fatigue and rapid general decline; admitted for about 2 weeks | WBC 216 × 10⁹/L (98% lymphocytes), Hb 7.1 g/dL, platelets 61 × 10⁹/L, Na 127 and K 3.3 mmol/L, HCO3 14–16.5 mmol/L, severe hypoxaemia | Broad-spectrum antibiotics and supportive care |
| June to September 2025 | Oropharyngeal dysphagia with recurrent aspiration pneumonia; NG tube feeding for about 3 months; weakness and impaired balance; temporary discharge in early July (walking independently, off oxygen); PEG considered | CRP up to 194 mg/L | Successive antibiotic courses, including vancomycin and meropenem; in the last episode, failure of meropenem and response to piperacillin–tazobactam; swallowing rehabilitation (exercises and NMES) |
| Mid-June to October 2025 (about 4 months) | Ibrutinib; nosebleeds | WBC 298 → 218 × 10⁹/L in the first month; Hb 9.6 → 8.2 g/dL; platelets about 90 × 10⁹/L | Ibrutinib 280 mg daily via the NG tube, increased to 420 mg after about 3 weeks |
| September to October 2025 | Infection resolved; swallowing and walking recovered; NG tube removed; PEG not needed | — | Ibrutinib continued |
| October 2025 | Inadequate disease response after about 4 months of ibrutinib | — | Venetoclax + rituximab on the MURANO schedule; started in hospital with TLS prophylaxis; antibiotics in the first weeks |
| Week 2 of venetoclax | — | WBC about 3 × 10⁹/L | Dose ramp-up continued |
| The following months | Full return of strength and activity | WBC within or close to the normal range, fluctuating | Rituximab for 6 cycles; venetoclax 400 mg daily |
| October 2026 (about 12 months after starting venetoclax) | About 1 hour of walking and exercise a day; normal activity | WBC about 7 × 10⁹/L | Venetoclax continues to a total of 24 months from cycle 1 day 1 of rituximab |
MRD, IGHV status and testing for del(17p) and TP53 mutation were not performed.
Indication for treatment
During the years of monitoring, the only finding was lymphocytosis (Rai 0). The absolute lymphocyte count alone is not a criterion for starting treatment, and in asymptomatic early-stage disease, early treatment, even with targeted agents, has not shown an overall survival benefit [1, 2]. In spring 2025, the anaemia (Hb below 10 g/dL) and thrombocytopenia (below 100 × 10⁹/L) were consistent with the iwCLL criterion of progressive marrow failure [1, 2].
Why switch treatment?
Persistent lymphocytosis in the first months of ibrutinib is not by itself a sign of failure: in the CLL studies, 66% of patients on single-agent ibrutinib had a rise in lymphocyte count that began in the first month and resolved by a median of 14 weeks (range 0.1 to 104 weeks) [7]. The decision to switch was based on the whole clinical course: after about 4 months, the disease was not under control on ibrutinib, and the patient had just come through months of severe infections with a dwindling response to antibiotics; the aim was rapid, deep disease control with a time-limited treatment.
The EHA 2026 guideline recommends switching to a venetoclax-based regimen or pirtobrutinib after progression on a covalent BTK inhibitor (cBTKi); response rates to venetoclax after cBTKi failure have been 70% to 80%, and VenR, being time-limited, is often preferred, particularly in patients with comorbidities or intolerance of a cBTKi [1]. In a phase 2 trial of single-agent venetoclax after ibrutinib, the overall response rate was 65% (59 of 91 patients) [8].
MURANO (389 patients with R/R CLL after 1 to 3 prior lines including at least one chemotherapy-containing regimen; ECOG 0 or 1): 2-year PFS 84.9% with VenR vs 36.3% with BR (HR 0.17), with a similar benefit in patients with del(17p) (81.5% vs 27.8%) [3]. In the final analysis, at a median follow-up of 7 years, median PFS was 54.7 vs 17.0 months and 7-year OS 69.6% vs 51.0% [4]. With prior ibrutinib and poor performance status, this patient was outside the MURANO population; because the benefit of VenR was seen with and without del(17p), the lack of a TP53 result did not stand in the way of choosing it [3].
TLS prevention
An ALC far above 25 × 10⁹/L put the patient at least in the medium TLS-risk group. For high tumour burden (any lymph node 10 cm or larger, or ALC 25 × 10⁹/L or higher with any lymph node 5 cm or larger), the FDA label recommends oral and intravenous hydration, allopurinol (and rasburicase if baseline uric acid is raised) and admission for the first 20 mg and 50 mg doses, with blood chemistry before the dose and at 4, 8, 12 and 24 hours; for medium risk with CLcr below 80 mL/min, admission is also considered [5]. This patient's treatment was started in hospital with these preventive measures. TLS diagnostic criteria: Tumour lysis syndrome: Cairo-Bishop criteria.
Venetoclax + rituximab (MURANO schedule and FDA label)
Venetoclax + rituximab (VenR)
Relapsed or refractory CLL
Relapsed or refractory CLL
| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Ramp-up: 5 weeks | |||
| Venetoclax | Week 1: 20; week 2: 50; week 3: 100; week 4: 200; week 5: 400 mg | Oral, with food and water | Once daily |
| Cycles 1 to 6 (28-day cycles) | |||
| Rituximab | Cycle 1: 375 mg/m²; cycles 2 to 6: 500 mg/m² | Intravenous | Day 1 of each cycle |
| From cycle 1 day 1 to 24 months | |||
| Venetoclax | 400 mg | Oral, with food and water | Once daily |
Rituximab starts in week 6, i.e. after the 5-week ramp-up, whose last week is 7 days of venetoclax 400 mg [3, 5]. Before rituximab, screen for hepatitis B (risk of HBV reactivation) and monitor for infusion-related reactions, especially with the first infusion [6]. Grade 3 or 4 neutropenia occurred in 63% to 64% of patients with CLL on venetoclax; monitor blood counts [5]. Strong CYP3A inhibitors are contraindicated at initiation and during the ramp-up; with a moderate CYP3A inhibitor, the dose is reduced by at least 50% [5]. Do not give live vaccines before, during or after treatment until B-cell recovery [5].
Evidence: MURANO (2018)
Doses follow the trial protocol, guideline or official drug label (source given in the notes of each regimen). Before prescribing, check blood counts, renal and hepatic function, drug interactions and the patient’s condition, and adjust the dose according to the drug label.
Response and follow-up
The haematological response was rapid: WBC about 3 × 10⁹/L at week 2 and since then within or close to the normal range (now about 7). MRD and genetic tests were not performed, and no formal iwCLL response assessment (imaging and bone marrow) has been reported, so this is a clinical and haematological response. In MURANO, patients with undetectable MRD at the end of treatment had a median PFS from the end of treatment of 52.5 months, vs 18.0 months in patients with detectable MRD [4].
Practical points
- The lymphocyte count alone is not an indication for treatment; base the decision on the iwCLL criteria [1, 2].
- In an older patient with recurrent infections, review all concomitant medicines; azoles and other CYP3A inhibitors change the venetoclax dose [5].
- A high tumour burden does not rule out venetoclax, but it requires inpatient initiation, the 5-week ramp-up and TLS prophylaxis [5].
- After an inadequate response to or progression on a cBTKi, a time-limited venetoclax-based regimen is a well-supported option [1, 8].
- With patients who fear "chemotherapy", explaining how today's targeted treatments differ from classic chemotherapy makes shared decision-making possible.
Scientific evidence
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Scientific evidence
4 itemsThe MURANO study: final analysis and retreatment/crossover substudy results of VenR for patients with relapsed/refractory CLL
Venetoclax–Rituximab in Relapsed or Refractory Chronic Lymphocytic Leukemia
EHA Guidelines on management of chronic lymphocytic leukemia and Richter transformation
iwCLL guidelines for diagnosis, indications for treatment, response assessment, and supportive management of CLL
Read more
Related links
Related cancer types
Treatment guides
References
11 referencesShow all references, 5 with a study cardClose the reference list
Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
- 1
- 2
- 3
- 4
- 5
- 6
- 7IMBRUVICA (ibrutinib) capsules, tablets and oral suspension — Prescribing Information
- 8
- 9Ibrutinib as Initial Therapy for Patients with Chronic Lymphocytic Leukemia
- 10
- 11
This page is based on reputable scientific sources and was last updated on 31 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.
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