Choosing the Optimal Induction Therapy for an Individual Patient
The primary goal of every physician is to provide their patients with the best quality-of-life, together with a minimum burden of therapy needed to extend their lives. The patient in this case has two of the most common indications for therapy, according to the CRAB criteria (Calcium disturbance, Renal insufficiency, Anemia and Bone Disease).4 Achieving a complete remission, as defined by IMWG criteria, is the single most important surrogate end point for long-term disease control.5  

Once the decision to treat is made, the optimal induction therapy for that specific patient should be chosen. Prior to the year 2000, induction therapy for multiple myeloma consisted of alkylator-based or pulse dexamethasone-based regimens. After 2000, the availability of immune modulatory agents (IMIDs) — such as thalidomide and lenalidomide, and the proteasome inhibitor bortezomib — has increased the therapeutic armamentarium. Randomized trials and meta-analysis have shown that bortezomib-based induction therapy is superior to traditional induction regimens in both the transplant eligible and ineligible patients.6–10

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The most important features in the history and physical exam that may impact the selection of initial induction therapy for multiple myeloma are summarized in Table 2. For this patient, optimal induction therapy would include triple drug therapy (IMID, proteasome inhibitor, and steroids) with careful monitoring of hematologic parameters due to the patient’s mild renal insufficiency.

Table 2. Factors to Consider in Deciding Induction Therapy for Multiple Myeloma11

High tumor burden

  • Pulse dexamethasone
  • Combination therapies with alkylators and IMIDS and bortezomib
Renal failure

  • Pulse dexamethasone
  • Combination therapies with alkylators and thalidomide and bortezomib (role of lenalidomide uncertain)
Hypercalcemia

  • Pulse dexamethasone
  • Bisphosphonates
Frail

  • Avoid high dose dexamethasone
Clotting or bleeding history

  • Assess risk of use of lenalidomide/thalidomide and anticoagulation
Pre-existing neuropathy

  • Assess use of bortezomib/thalidomide
Cytogenetic abnormalities

  • Indication for bortezomib/lenalidomide

In preparation for therapy, it is essential that the patient be informed of the potential side effects of each drug. Steroids are likely to cause hyperglycemia. Since this patient was not diabetic, nutritional counseling and weekly monitoring of blood sugars should be enough to screen for steroid-induced hyperglycemia. Fluid retention with dexamethasone is not uncommon, and patients should be educated on the signs and symptoms of fluid retention such as weight gain and edema, and encouraged to reduce salt consumption.

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Hematologic Cancers Multiple Myeloma The Advisory Board