Do you stop pomalidomide (Imnovid) in the event of an infection?

Management of Pomalidomide During Infections in Multiple Myeloma

Pomalidomide should be temporarily discontinued during active infection until the infection has resolved, as it increases infection risk and may impair recovery. 1

Rationale for Discontinuation

Pomalidomide therapy is associated with a significant infection risk in multiple myeloma patients:

• Approximately 30% of patients treated with pomalidomide plus low-dose dexamethasone experience grade 3-4 infections, mainly during the first three months of therapy 1
• Infections occur in 33.7% of patients on pomalidomide, with pneumonia being the most common serious infection (13.9%) 2
• Infections are the most common serious adverse event in patients receiving pomalidomide-containing regimens, occurring in 17% of patients 1

Risk Assessment and Management Algorithm

1. When infection is diagnosed:

   • Immediately discontinue pomalidomide
   • Initiate appropriate antimicrobial therapy
   • Monitor infection response

2. For mild infections:

   • Hold pomalidomide until complete resolution of infection
   • Resume at same dose once infection has cleared

3. For severe infections:

   • Discontinue pomalidomide until complete resolution
   • Consider dose reduction upon restarting (from 4 mg to 3 mg)
   • Implement prophylactic antibiotics when restarting therapy

4. For life-threatening infections:

   • Discontinue pomalidomide immediately
   • Reassess risk-benefit before considering reintroduction

Special Considerations

Neutropenia Management

• Pomalidomide commonly causes neutropenia (56.2% grade 3/4) 2, which increases infection risk
• If neutropenic fever develops, immediately discontinue pomalidomide and administer G-CSF support
• Consider prophylactic antibiotics when restarting pomalidomide, especially during the first three months 1

Renal Impairment

• Pomalidomide does not require dose modification for renal function 3, but infection risk may be higher
• More careful monitoring is required in patients with renal impairment during infections

Elderly Patients

• Patients >75 years should receive reduced dexamethasone (20 mg weekly instead of 40 mg) when pomalidomide is restarted 2
• Elderly patients may require lower starting doses of pomalidomide (3 mg instead of 4 mg) after infection resolution 3

Resuming Therapy After Infection

When restarting pomalidomide after infection:

1. Ensure complete resolution of infection symptoms
2. Perform baseline laboratory monitoring including CBC with differential
3. Consider prophylactic antibiotics for the first three months of therapy 1
4. Resume at previous effective dose if infection was uncomplicated, or consider dose reduction if severe infection occurred

Common Pitfalls to Avoid

• Continuing pomalidomide during active infection: This may prolong the infection and increase the risk of complications
• Failing to implement antibiotic prophylaxis: Routine antibiotic prophylaxis should be considered for the first three months of pomalidomide therapy 1
• Overlooking drug interactions: Quinolone antibiotics must be used with caution due to common metabolic pathways that can increase pomalidomide exposure 1
• Permanent discontinuation: While temporary discontinuation is recommended during infection, permanent discontinuation may lead to disease progression; planned resumption after infection resolution is preferred 4

By following these guidelines, clinicians can effectively manage infections in multiple myeloma patients on pomalidomide therapy while maximizing treatment efficacy and minimizing complications.