How to manage anemia in patients taking talquetamab?

Management of Anemia in Patients Taking Talquetamab

For patients taking talquetamab who develop anemia, intravenous iron therapy should be administered for iron deficiency, followed by erythropoiesis-stimulating agents (ESAs) if hemoglobin remains low, with red blood cell transfusions reserved for severe symptomatic anemia. 1, 2

Understanding Anemia with Talquetamab

• Anemia is a common adverse event in patients receiving talquetamab, with grade 3-4 anemia occurring in approximately 26-31% of patients across different dosing regimens 2
• Talquetamab is a bispecific antibody targeting GPRC5D on myeloma cells and CD3 on T cells, approved for relapsed/refractory multiple myeloma after at least 4 prior therapies 1
• Hematologic toxicities, including anemia, are expected with talquetamab therapy and require proactive monitoring and management 2, 3

Initial Assessment of Anemia

• Evaluate for iron deficiency and other correctable causes of anemia before initiating specific anemia therapy 1, 4
• Check iron studies including serum ferritin and transferrin saturation (TSAT) to diagnose:
  • Absolute iron deficiency (serum ferritin < 100 ng/mL)
  • Functional iron deficiency (TSAT < 20% and serum ferritin > 100 ng/mL) 1, 4
• Monitor hemoglobin levels regularly during talquetamab therapy, as anemia is one of the most common grade 3-4 adverse events 2, 5

Management Algorithm

Step 1: Iron Replacement

• For patients with confirmed iron deficiency:
  • Administer intravenous (IV) iron rather than oral iron, which is less effective during cancer therapy 1, 4
  • For absolute iron deficiency: administer IV iron according to approved product labels until correction of deficiency 1
  • For functional iron deficiency: administer 1000 mg iron as single or multiple doses according to available IV iron formulations 1, 4
• Timing consideration: In patients receiving potentially cardiotoxic chemotherapy, administer IV iron either before or after (not on the same day) chemotherapy administration 1

Step 2: ESA Therapy

• If anemia persists after iron replacement or is not related to iron deficiency, consider ESA therapy for patients with hemoglobin < 10 g/dL who are symptomatic or < 8 g/dL even if asymptomatic 1, 4
• Recommended ESA dosing:
  • Epoetin alpha, beta, or zeta: approximately 450 IU/week/kg body weight
  • Darbepoetin alpha: 6.75 mg/kg body weight every 3 weeks or 2.25 mg/kg body weight weekly
  • Epoetin theta: 20,000 IU once weekly 1, 4
• Target hemoglobin level should be a stable 12 g/dL without requiring red blood cell transfusions 1
• Avoid hemoglobin rise of > 2 g/dL over a 4-week period 4
• If no response after 4-8 weeks of ESA therapy, discontinue ESA as further treatment is unlikely to be beneficial 1

Step 3: Red Blood Cell Transfusions

• For patients with hemoglobin < 7-8 g/dL or severe anemia-related symptoms (even at higher hemoglobin levels), administer red blood cell transfusions without delay 1, 4
• Transfuse only the minimum number of RBC units necessary to relieve symptoms or return to a safe hemoglobin range 4
• Consider transfusions as a bridge therapy while waiting for response to iron therapy and/or ESAs 1

Special Considerations for Talquetamab Patients

• Anemia management should be coordinated with management of other common talquetamab-related adverse events such as cytokine release syndrome, skin toxicities, and dysgeusia 3, 5
• Monitor for infections, which are common in talquetamab-treated patients (59-76%) and may exacerbate anemia 2, 3
• Consider dose modification of talquetamab only if severe (grade 4) anemia persists despite appropriate management 1, 6
• The biweekly dosing schedule of talquetamab (800 μg/kg every 2 weeks) may be associated with fewer grade 3-4 adverse events compared to weekly dosing 2, 6

Monitoring and Follow-up

• Monitor hemoglobin levels weekly during initial talquetamab therapy and then every 2-4 weeks once stable 4, 5
• Evaluate for symptoms of anemia at each visit, including fatigue, weakness, decreased exercise tolerance, and dyspnea 4
• Reassess iron status periodically, especially in patients receiving ongoing ESA therapy 1, 4

Cautions and Contraindications

• ESA therapy should be used cautiously as it may affect mortality in cancer patients if target hemoglobin levels exceed 12 g/dL 1, 4
• Avoid ESA therapy in patients with active malignancy who are not receiving chemotherapy 1, 4
• Be aware that talquetamab can cause multiple cytopenias simultaneously; management may need to address neutropenia and thrombocytopenia alongside anemia 2, 6