What is the diagnosis and treatment for multiple myeloma (Plasma Cell Myeloma)?

From the Guidelines

Multiple myeloma diagnosis must include the criteria updated in 2014 by the International Myeloma Working Group, and treatment typically involves a combination approach based on disease stage and patient factors, with standard regimens including proteasome inhibitors, immunomodulatory drugs, and corticosteroids, as well as high-dose chemotherapy followed by autologous stem cell transplantation for eligible patients. The diagnosis of multiple myeloma is based on specific criteria, including the presence of monoclonal plasma cells in the bone marrow, elevated levels of monoclonal protein in the blood or urine, and evidence of end-organ damage such as anemia, bone lesions, or kidney failure 1.

Key Considerations

• For patients under 70 years in good clinical condition, induction followed by high-dose therapy with autologous stem cell transplantation (ASCT) is the standard treatment, as it offers improved outcomes 1.
• For relapsed/refractory multiple myeloma, the most commonly used regimens are proteasome inhibitor- or lenalidomide-containing regimens, with new triplet combinations increasing progression-free survival 1.
• In advanced cases, pomalidomide plus low-dose dexamethasone and daratumumab are approved treatments, offering improved outcomes for patients with limited treatment options 1.

Treatment Approaches

• Standard regimens include proteasome inhibitors (bortezomib, carfilzomib), immunomodulatory drugs (lenalidomide, pomalidomide), and corticosteroids (dexamethasone) 1.
• High-dose chemotherapy followed by autologous stem cell transplantation offers improved outcomes for eligible patients, with newer treatments including monoclonal antibodies like daratumumab and isatuximab, which target specific proteins on myeloma cells 1.
• Supportive care is essential and includes bisphosphonates for bone disease, pain management, and prevention of infections, with regular monitoring through blood tests, bone marrow examinations, and imaging studies helping to guide ongoing treatment decisions and manage complications like anemia, infections, kidney problems, and bone fractures.

Recent Guidelines

• The European Myeloma Network recommends risk stratification to classify patients for International Staging System stage and for cytogenetically defined high- versus standard-risk groups, with novel-agent-based induction and up-front autologous stem cell transplantation in medically fit patients remaining the standard of care 1.
• The Blood Cancer Journal provides algorithms for the treatment of newly diagnosed and relapsed multiple myeloma based on the best available evidence, with a focus on risk stratification and individualized treatment approaches 1.

From the FDA Drug Label

14 CLINICAL STUDIES 14. 1 Newly Diagnosed Multiple Myeloma Combination Treatment with Lenalidomide and Dexamethasone in Patients Ineligible for Autologous Stem Cell Transplant

MAIA (NCT02252172), an open-label, randomized, active-controlled trial, compared treatment with DARZALEX 16 mg/kg in combination with lenalidomide and low-dose dexamethasone (DRd) to treatment with lenalidomide and low-dose dexamethasone (Rd) in patients with newly diagnosed multiple myeloma ineligible for autologous stem cell transplant.

The diagnosis of multiple myeloma (Plasma Cell Myeloma) is not directly stated in the provided text, but it can be inferred that diagnosis is based on International Myeloma Working Group (IMWG) criteria. The treatment for multiple myeloma is:

• DARZALEX 16 mg/kg in combination with lenalidomide and low-dose dexamethasone (DRd)
• Lenalidomide (25 mg once daily orally on Days 1–21 of repeated 28-day [4-week] cycles)
• Low dose oral or intravenous dexamethasone 40 mg/week (or a reduced dose of 20 mg/week for patients >75 years or body mass index [BMI] <18.5) 2 2

From the Research

Diagnosis and Treatment of Multiple Myeloma

• Multiple myeloma, also known as plasma cell myeloma, is an incurable disease that requires multiple lines of therapy 3.
• The diagnosis and treatment of multiple myeloma involve various agents and combinations, including lenalidomide, bortezomib, and dexamethasone 4, 5, 6, 7.

Treatment Options

• Lenalidomide is a second-generation immunomodulatory medication that can be used in combination with other medications, such as dexamethasone, bortezomib, ixazomib, carfilzomib, and daratumumab, to treat multiple myeloma 7.
• The combination of bendamustine, lenalidomide, and dexamethasone (BRD) has been shown to be effective in relapsed multiple myeloma, with high response rates and durable responses 4.
• The combination of bendamustine, low-dose dexamethasone, and lenalidomide (BdL) has also been shown to be a promising treatment for patients with relapsed/refractory multiple myeloma 6.

Relapsed/Refractory Multiple Myeloma

• In the setting of relapsed/refractory multiple myeloma, daratumumab and pegylated liposomal doxorubicin have been shown to have a higher probability of achieving better progression-free survival (PFS) 3.
• The addition of a second or third novel agent to either immunomodulatory (IMID) or proteasome inhibitor (PI) backbone may improve survival, although severe adverse events may be more frequent with certain agents 3.

Lenalidomide-Based Treatments

• Lenalidomide-based treatments have been shown to be effective in multiple myeloma, with favorable response rates, tolerable toxicity, and therapeutic benefits 7.
• However, caution is warranted to prevent the onset of peripheral neuropathy and other side effects, such as cardiovascular events, hematocrit, and infections 7.