Considerations for Relapsed Myeloma Should Match Patient, Disease, and Therapy

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Selecting therapies for patients with multiple myeloma is challenging because the disease is inherently heterogeneous.
Selecting therapies for patients with multiple myeloma is challenging because the disease is inherently heterogeneous.

Selecting the appropriate treatment for patients with multiple myeloma is a complex decision that needs to be based on multiple patient and disease characteristics.

Treatment selection in patients with newly diagnosed multiple myeloma has been streamlined as a result of recent clinical trials that showed the benefit of treatment with 3-drug combinations.1 But treating relapsed disease has become quite difficult for the practicing clinician, according to Joseph Mikhael, MD, MEd, chief medical officer of the International Myeloma Foundation.

“It is really a very heterogeneous disease, meaning some patients will succumb to disease after only a few years and some can live 10, 15, or 20 years,” Dr Mikhael said. “Tailoring treatment to an individual can be a challenge because there is not an ideal sequence or algorithm that has been developed.”

This difficulty reflects the increasing number of treatment choices available to patients and clinicians. In recent years, the US Food and Drug Administration has granted numerous approvals including daratumumab combined with lenalidomide and dexamethasone or bortezomib and dexamethasone,2 elotuzumab combined with lenalidomide and dexamethasone,3 ixazomib combined with lenalidomide and dexamethasone,4 single-agent daratumumab,5 carfilzomib with lenalidomide and dexamethasone,6 and more.

The simplest way to approach treatment selection, Dr Mikhael said, is to consider the 3 major classes of drugs available for these patients: proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies. Most regimens will involve 2 out of the 3, plus a steroid, he said.

“There have been a series of phase 3 studies presented and published in the last 2 to 3 years validating the use of these combinations,” Dr Mikhael said.

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