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Newer drugs such as ofatumumab, ibrutinib, idelalisib (Zydelig), and venetoclax (Venclexta) may be other options.

If the leukemia responds, stem cell transplant may be an option for some patients.

Sometimes very high numbers of leukemia cells in the blood cause problems with normal circulation. Chemo may not lower the number of cells until a few days after the first dose, so before the chemo is given, some of the cells may be removed from the blood with a procedure called leukapheresis. The effect lasts only for a short time, but it may help until the chemo has a chance to work.

Leukapheresis is also sometimes used before chemo if there are very high numbers of leukemia cells (even when they aren’t causing problems) to prevent tumor lysis syndrome (this was discussed in the chemotherapy section).

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If the initial treatment is no longer working or the disease comes back, another type of treatment may help.If the initial response to the treatment lasted a long time (usually at least a few years), the same treatment can often be used again.If the initial response wasn't long-lasting, using the same treatment again isn't as likely to be helpful.Some people may have a good response to first-line treatment (such as fludarabine) but may still have some evidence of a small number of leukemia cells in the blood, bone marrow, or lymph nodes. CLL can't be cured, so doctors aren't sure if further treatment right away will be helpful.Some small studies have shown that alemtuzumab can sometimes help get rid of these remaining cells, but it's not yet clear if this improves survival.

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