How to manage facial swelling in a patient taking acalabrutinib (Bruton's tyrosine kinase inhibitor) for cancer treatment?

Management of Acalabrutinib-Induced Facial Swelling

Facial swelling in patients taking acalabrutinib should be managed conservatively with limb elevation, compression measures, and sodium restriction as first-line interventions, while ruling out serious complications such as angioedema or infection. 1

Initial Assessment and Differential Diagnosis

When evaluating facial swelling in a patient on acalabrutinib, immediately assess for:

• Signs of angioedema or severe allergic reaction (lip/tongue swelling, respiratory distress, urticaria) requiring emergency intervention 2
• Infectious causes including herpes simplex virus, herpes zoster, or Staphylococcus aureus superinfection, which are common with BTK inhibitors 1
• Periorbital edema specifically, which can occur with acalabrutinib though less commonly than with other tyrosine kinase inhibitors 2
• Vital signs and lymphadenopathy to exclude DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) 2

Conservative Management Strategy

For simple peripheral/facial edema without inflammatory features:

• Implement conservative measures first: limb/head elevation, compression garments if applicable, and sodium restriction 3
• Continue acalabrutinib without interruption if the swelling is mild (grade 1-2) and non-inflammatory, as peripheral edema occurs in a subset of patients but is generally manageable 1, 4
• Monitor closely for progression with serial assessments every 3-7 days 2

When to Hold or Modify Acalabrutinib

Temporarily discontinue acalabrutinib if:

• Grade 3 or higher severity (severe consequences requiring hospitalization or limiting self-care activities) 2
• Associated inflammatory features such as erythema, pain, or systemic symptoms suggesting dermatologic toxicity 1
• Suspected infection requiring treatment, particularly herpes virus reactivation or bacterial cellulitis 1

Pharmacologic Interventions

For persistent or symptomatic facial swelling:

• Antihistamines may be considered for associated pruritus or allergic-type features 2
• Short course of oral corticosteroids (prednisone 0.5-1 mg/kg/day) if inflammatory component is present, with taper over at least 4 weeks 2
• Avoid systemic steroids if simple fluid retention without inflammation, as this differs from chemotherapy-induced inflammatory edema 3

Resuming Therapy

After resolution or downgrading to grade 1:

• Restart acalabrutinib at full dose (100 mg twice daily) if the adverse event was grade 2 or lower and resolved with conservative measures 4, 5
• Consider dose reduction only if recurrent grade 3 events occur, though most patients tolerate full-dose resumption 4, 5
• Reeducate patients about adherence and adverse event management strategies, as this improves outcomes 4

Critical Pitfalls to Avoid

• Do not automatically discontinue acalabrutinib for mild facial swelling, as most dermatologic adverse events are grade 1-2 and manageable without treatment interruption 1, 4
• Do not confuse simple edema with inflammatory dermatologic toxicity requiring steroids—acalabrutinib-induced edema lacks the burning pain, erythema, and progressive skin changes seen with chemotherapy agents 3, 6
• Do not overlook infectious complications, particularly herpes virus reactivations and staphylococcal superinfections, which are among the most common dermatologic adverse events with BTK inhibitors 1
• Monitor for atrial fibrillation if initiating systemic steroids or other medications, as acalabrutinib carries a 4.1% risk of atrial fibrillation (lower than ibrutinib's 3-16%) 2

Long-Term Monitoring

• Most acalabrutinib dermatologic toxicities occur during the first year and decline over time 1
• Track adherence patterns when doses are missed or modified, as nonadherence can be addressed through patient education 4
• Dermatology consultation is warranted for persistent, severe, or atypical presentations requiring biopsy or specialized management 2