Exercise and normal life: keep training, adjust only for specific situations¶
11.1 What guidance says¶
All the relevant guidance encourages activity [E].
- Swedish CLL guideline. Patients "bör … uppmuntras att vara fysiskt aktiva och fortsätta med sina dagliga aktiviteter, oavsett om de får någon behandling eller inte" (should be encouraged to stay physically active and continue daily activities, whether or not they are treated). The treating doctor should individualise advice according to treatment intensity, infection susceptibility and blood counts (VP8.2 §18.6, §19.1.3).
- The patient leaflet. "För övrigt finns ingen anledning att du ska ändra på dina levnadsvanor" (otherwise there is no reason to change your habits).
- Sweden's national cancer-rehabilitation programme:
- Dose: at least 150 minutes a week of moderate activity, or 75 minutes of vigorous activity, plus muscle-strengthening work twice a week.
- Strength of evidence: ++++ for reducing fatigue and improving function and quality of life; +++ for fitness and strength.
- Both high-intensity interval training (HIIT) and moderate continuous training can be recommended.
- "Pågående infektion är en absolut kontraindikation för träning" (an ongoing infection is an absolute contraindication to training).
- Physical activity on prescription (FaR) is suggested as a useful tool.
- Source: VP Cancerrehabilitering §9.2.
- EHA 2026 "strongly advised" aerobic exercise.
- The American College of Sports Medicine (2019) says every cancer survivor should "avoid inactivity". It gives no numeric blood-count thresholds (ACSM 2019).
11.2 The evidence that exercise helps, and its limits¶
In blood cancers generally. A Cochrane review of 18 trials found exercise "probably improves fatigue" (SMD 0.31, moderate certainty), with no effect on mortality (Knips 2019, abstract only).
In CLL specifically the studies are small:
- a 2025 systematic review found only 6 studies, with 323 patients in total (Cunha 2025);
- 12-week HIIT plus strength programmes in untreated CLL were feasible: 99% of prescribed minutes were completed, and strength ended 35–56% higher than in controls (MacDonald 2021);
- a randomised UK pilot of 28 untreated patients raised lean mass by 2% (Brown 2024);
- a 2026 pilot trial of 36 patients on treatment improved grip strength and cognitive fatigue, with no exercise-related adverse events (Sci Rep 2026);
- a 63-patient trial reporting less frailty is a preprint, not yet peer reviewed (preprint).
What patients report. In a UK survey, 77% of people with CLL reported fatigue and 55% insomnia. 79% wanted exercise programmes, and 70% had never received any exercise guidance (Miles 2025).
Lifestyle before diagnosis. In a Mayo/Scandinavian cohort, physical activity, smoking and alcohol before diagnosis did not change time to first treatment (Glimelius 2024).
[I] Exercise improves fitness, fatigue, mood and probably tolerance of treatment. It has not been shown to slow CLL, and being fit is not a prognostic signal.
11.3 Real contraindications versus unnecessary restriction¶
| Situation | Practical response | Basis |
|---|---|---|
| Infection or fever (≥38.0 °C) | Pause training and contact the clinic | Swedish rehabilitation programme: absolute contraindication [E] |
| Untreated, normal blood counts | No restriction: aerobic, strength, HIIT, outdoor exercise and ordinary gyms are all fine | VP8.2; CLL pilot trials enrolled exactly this group [E/I] |
| Platelets well below ~50×10⁹/L | Avoid contact, collision and high-fall-risk sport. Exercise trials paused structured training below about 10–20×10⁹/L | Convention, not outcome evidence (Elter 2009; Yang 2022) |
| Symptomatic anaemia (conventional cut-off Hb ~8 g/dL) | Reduce intensity | Convention |
| Neutropenia during treatment | Avoid crowded gyms; no numeric cut-off exists | [I] by analogy with transplant advice |
| Enlarged or palpable spleen | Avoid collision sport and blows to the left upper abdomen until a clinician has assessed the spleen | [I] by analogy with mononucleosis. No CLL data. In a review of atraumatic splenic rupture, 30.3% of cases had a neoplastic cause and related mortality was 12.2% (Renzulli 2009) |
| On a BTK inhibitor | Reconsider high-trauma sports (boxing, martial-arts sparring, rugby, downhill mountain biking), especially if also taking anticoagulant or antiplatelet drugs. Avoid NSAIDs for sports injuries and ask which painkiller to use. Expect bruising | SmPC bleeding warnings; cardiology sports guidance says contact sport should be avoided on oral anticoagulants (ESC 2020) [E/I] |
| On a BTK inhibitor, during exercise | Stop and get an ECG for new palpitations, irregular pulse, fainting, chest pain or breathlessness. Get blood pressure controlled before heavy resistance or HIIT work | SmPCs; ESC 2022. Athletes already carry a higher AF risk (OR 2.46); [S] that risk may add to the drug's (Newman 2021) |
| Venetoclax dose ramp-up | Drink 1.5–2 L a day from 2 days before the first dose. Avoid dehydration from long sessions in heat or sauna, especially around dose increases. Ask whether to skip hard sessions on blood-test days | Venclyxto SmPC [E]; the lab-day point is [S] |
| Joint and muscle pain | Commoner on ibrutinib than on acalabrutinib or zanubrutinib; headache at start is commonest with acalabrutinib; often transient | VP8.2 §12.1 [E] |
| Fatigue | Pace activities, rest or nap when needed, and keep moving; activity itself reduces fatigue | VP8.2 patient leaflet; rehabilitation programme [E] |
Unnecessary for an untreated patient with normal counts: blanket rest; avoiding outdoor exercise or ordinary gyms; avoiding strength training or high-intensity training.
The NSAID caution rests on the ibrutinib package leaflet, which lists NSAIDs such as ibuprofen and naproxen among drugs that raise bleeding risk, and on an expert review that advises people on ibrutinib against NSAIDs, fish oils, vitamin E and aspirin-containing products (Shatzel 2017, abstract only). [I] Extending it to the other BTK inhibitors is an inference from their shared bleeding warnings (section 7.3).
11.4 Lifestyle: what actually matters¶
- Smoking. Smoking does not cause CLL, but people with CLL have more lung cancer: a standardised incidence ratio of 1.61, rising to 2.22 under age 60 (Schöllkopf 2007). Sweden's quit line is 020-84 00 00 (VP8.2 ch. 19).
- Alcohol. During treatment, alcohol "kan öka risken för blödningar och infektioner" (can increase the risk of bleeding and infection) and can interact with liver-metabolised drugs (VP8.2 ch. 19).
- Diet and weight. General Swedish dietary advice applies. No diet has been shown to slow CLL. EHA's phrase "a healthy diet without processed ingredients" is advice, not a tested intervention.
- Sleep. Insomnia is common (about 55% in the UK survey). Physical activity during treatment improves sleep, according to the Swedish guideline.
- Supplements:
- Vitamin D. Evidence is observational only. Insufficiency was associated with shorter time to treatment (multivariable HR 1.47) (Shanafelt 2011). A retrospective cohort linked supplement use to longer treatment-free survival, a design open to confounding (Tadmor 2024). EHA does not recommend routine supplements (III, C). [I] Checking for and correcting a deficiency under general guidance is reasonable; expecting it to delay CLL is not.
- Green-tea extract (EGCG). The supporting data come from one single-arm trial at 2,000 mg twice daily (Shanafelt 2013). That dose is far above the 800 mg/day at which EFSA found liver-enzyme rises (EFSA 2018). Avoid high-dose extracts. Ordinary brewed tea is generally considered safe at usual intakes.
- Curcumin. Anecdotal and laboratory data only.
- Infection exposure:
- Wash hands, especially at meals and after the toilet.
- Avoid people with active infections.
- Avoid large crowds in flu season when susceptibility is high.
- Do not isolate. Sweden says advice must be balanced "så att patienter och närstående inte isolerar sig" (so that patients and families do not isolate themselves) (VP8.2 §18.5), and EHA notes that outdoor infection risk is "very limited".
- A "neutropenic diet" did not reduce infections in a meta-analysis (RR 1.02) (Jamal 2026). Food precautions, such as avoiding unpasteurised dairy, apply during treatment.
- Travel:
- No live vaccines: yellow fever and oral typhoid are excluded.
- Order the EU health insurance card (EU-kortet) from Försäkringskassan.
- Check that travel insurance covers a known CLL diagnosis.
- Carry enough medicine for the whole trip.
- Hepatitis B vaccination is recommended for longer or repeated trips to Asia, Africa or South America (1177 travel checklist; FoHM hepatitis B).
- Sun and skin:
- Squamous and basal cell skin cancers are "5–10 gånger vanligare" (5–10 times more common) in CLL and often more aggressive; melanoma is also more common and has a worse prognosis (VP8.2 ch. 14).
- In Denmark, the 10-year risk of any skin cancer was 13.5% vs 6.9% in matched controls (squamous cell 4.7% vs 1.4%) (Drejøe 2026, abstract only).
- Use daily UV protection, check your skin regularly, and have unclear lesions seen by a dermatologist.
- [I] A baseline full-skin examination is reasonable.
- Other cancers. Second cancers are about 1.6 times more common (SIR 1.63), and more so after treatment (van der Straten 2023). EHA advises taking part in population screening (III, B). Region Skåne runs cervical, colorectal and breast screening and organised prostate testing (OPT); eligibility details were not verified.
11.5 Food, supplement and drug interactions, relevant only once treatment starts¶
| Item | Venetoclax | Ibrutinib | Acalabrutinib | Zanubrutinib | Pirtobrutinib (EU) |
|---|---|---|---|---|---|
| Strong CYP3A inhibitors (e.g., clarithromycin, itraconazole, posaconazole, voriconazole) | Contraindicated at start and during ramp-up; afterwards ≤100 mg/day [SmPC] | 140 mg/day or pause ≤7 days [SmPC] | Avoid; pause the drug during short courses [SmPC] | 80 mg/day [SmPC] | No dose change in the EU; the US label says reduce by 50 mg [SmPC] |
| Moderate CYP3A inhibitors (e.g., fluconazole, ciprofloxacin, erythromycin, diltiazem, verapamil) | Avoid at start and during ramp-up; afterwards cut the dose by ≥50% [SmPC] | 280 mg/day [SmPC] | No change; monitor [SmPC] | 160 mg/day [SmPC] | No change [SmPC] |
| Grapefruit, Seville orange | Avoid (also starfruit) [SmPC] | Avoid; "must not be taken" with them [SmPC] | Not mentioned. Itraconazole raises exposure 5-fold, so avoiding them is a cheap precaution [I] | Counted as moderate inhibitors (→160 mg); "tell your doctor" [SmPC/leaflet] | Not mentioned; low CYP3A sensitivity [I] |
| St John's wort | Contraindicated [SmPC] | Contraindicated [SmPC] | Avoid [SmPC] | Avoid (strong inducer) [SmPC] | Not named; "if possible avoid strong CYP3A inducers" [SmPC] |
| Proton-pump inhibitors, antacids | No effect [SmPC] | No restriction [SmPC] | Capsules: avoid PPIs; separate from H2 blockers and antacids. Tablets: no restriction [SmPC] | No effect [SmPC] | No effect [SmPC] |
| Warfarin and other vitamin K antagonists | Monitor INR closely [SmPC] | Do not combine [SmPC] | Do not combine [SmPC] | Do not combine [SmPC] | "Not studied" [SmPC] |
| Fish oil, vitamin E, flaxseed | Not mentioned | SmPC: fish oil and vitamin E "should be avoided" | Not mentioned | Leaflet lists them as bleeding risks | Leaflet lists them as bleeding risks |
| Pause around surgery | None stated | 3–7 days before and after (instruction) | ≥3 days (consider) | 3–7 days (consider) | 3–5 days (consider); US label 3–7 |
Sources: EU SmPCs for Venclyxto, Imbruvica, Calquence, Brukinsa and Jaypirca, all as of 7 October 2026; Jaypirca US label.
Common herbal supplements. Ginkgo, garlic, turmeric, ginseng, green tea and echinacea are named in no EU product information. Studies in healthy volunteers, using test drugs rather than CLL drugs, mostly show modest effects:
- curcumin with piperine: no change in midazolam levels;
- green tea catechins (800 mg EGCG): buspirone exposure +20%;
- ginkgo: midazolam exposure −34%;
- ginseng: midazolam exposure −34%;
- garlic: saquinavir exposure −51%, the largest signal.
These compare with 3- to 24-fold changes from strong drug inhibitors (Volak 2013; Chow 2006; Piscitelli 2002). [I] The defensible message is: disclose every supplement; avoid St John's wort and concentrated extracts.
Ask a pharmacist to check all medicines and supplements for interactions. In a Mayo series, 64% of people starting ibrutinib were already taking a potentially interacting medicine. The authors recommend a formal pharmacist medication review (Finnes 2017).
Blood thinners and heart-rhythm drugs are specialist decisions.
- Sweden prefers a DOAC if anticoagulation is needed. Apixaban and rivaroxaban carry low interaction risk with BTKi; dabigatran carries more. A reduced dose such as apixaban 2.5 mg twice daily is a specialist judgement, not something to self-adjust (VP8.2 §12.1.4).
- Verapamil, diltiazem and amiodarone interact with BTKi. Experts therefore often prefer beta-blockers for rate control (Lipsky & Lamanna 2020).
- Dual antiplatelet therapy (two antiplatelet drugs) needs a cardiologist's input.