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Relapsed and Refractory

Some patients have residual leukemia cells in their bone marrow even after they receive intensive treatment. In these cases, the disease is referred to as being “refractory” (or “refractory ALL”).

Other patients achieve remission but later have decreased numbers of normal blood cells and a return of leukemia cells in their bone marrow. This is referred to as a “relapse” of the disease (or “relapsed ALL”). 

Relapsed/refractory disease is generally more difficult to treat. But there are treatment options available. Treatment for relapsed/refractory ALL is usually more intensive or complex than the treatment used following initial diagnosis. For these reasons, it is particularly important to consider getting opinions on treatment options from someone with expertise in managing relapsed/refractory ALL.

At the time of relapse, genetic testing of the leukemia cells may be performed. The mutational pattern at the time of relapse may be different from when the disease was first diagnosed, and this can affect treatment decisions.

Treatments for Relapsed/Refractory ALL

 Treatments for relapsed/refractory ALL may include:

  • A clinical trial
  • Chemotherapy
  • For patients with Ph+ ALL, a TKI given alone or as part of a chemotherapy regimen. In some cases, the TKI may be combined with a corticosteroid. If the TKI is part of a chemotherapy regimen, this regimen will usually be different from the one used during initial therapy. For some older patients who cannot tolerate chemotherapy, using a TKI along with a corticosteroid may be an option.
  • Nelarabine for patients with T-cell ALL
  • Blinatumomab (Blincyto®)
  • Inotuzumab ozogamicin (Besponsa®)
  • Allogeneic stem cell transplantation for physically fit patients with an available donor. Some older patients, as well as patients in poor health, may not be able to tolerate such an intense treatment.
  • CAR T-cell therapy, including:
    • Tisagenlecleucel (Kymriah®)
    • Brexucabtagene autoleucel (Tecartus®)

For information about the drugs listed on this page, visit Drug Listings.


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