Do you hold Pomalyst (pomalidomide) for a procedure?

Holding Pomalyst (Pomalidomide) for Procedures

While there is no specific guideline addressing pomalidomide discontinuation for procedures, you should hold pomalidomide for 3-7 days before and after surgical procedures based on the bleeding risk profile similar to other immunomodulatory agents used in multiple myeloma.

Rationale Based on Related Evidence

The evidence for holding pomalidomide comes from extrapolation of bleeding risk management in similar clinical contexts:

Bleeding Risk Considerations

• Thrombocytopenia is a major concern: Pomalidomide causes grade 3/4 thrombocytopenia in 24-57% of patients in real-world settings 1, 2
• Neutropenia occurs frequently: Grade 3/4 neutropenia affects 42-64% of patients, which increases infection risk perioperatively 1, 2
• Anemia is common: Grade 3/4 anemia occurs in 33-64% of patients 1

Analogous Guidance from Related Agents

• Ibrutinib precedent: For patients on ibrutinib (another agent used in hematologic malignancies with bleeding concerns), NCCN guidelines recommend holding the drug for 3-7 days before and after surgical procedures due to heightened bleeding risk 3
• This provides a reasonable framework for pomalidomide given its similar hematologic toxicity profile

Practical Management Algorithm

Pre-Procedure Assessment (1-2 weeks before)

• Check complete blood count to assess baseline platelet count, hemoglobin, and neutrophil count
• Verify platelet count >50,000/μL for moderate-risk procedures 4
• Assess INR and coagulation parameters if applicable 4
• Review concurrent anticoagulation/antiplatelet therapy 3

Timing of Drug Discontinuation

• Hold pomalidomide 3-7 days before the procedure (extrapolated from ibrutinib guidance) 3
• Consider the longer end (7 days) for:
  • Major surgical procedures
  • Patients with baseline thrombocytopenia
  • Procedures with high bleeding risk
  • Elderly patients (>75 years) who may have reduced drug clearance 1

Post-Procedure Resumption

• Hold pomalidomide 3-7 days after the procedure until adequate hemostasis is confirmed 3
• Verify platelet recovery before restarting if thrombocytopenia was present
• Ensure no active bleeding complications

Important Caveats

Patient-Specific Factors

• Elderly patients (>70 years) comprise 85.7% of pomalidomide users and may require more conservative management with longer drug holidays 1
• Dose reductions are required in 54.5% of patients, typically during the second cycle, suggesting variable drug tolerance 1
• Poor performance status patients (PS 3) have low tolerability and may require extended recovery time before restarting 1

Thromboprophylaxis Considerations

• Patients on pomalidomide-based regimens typically receive concurrent thromboprophylaxis (aspirin, warfarin, or LMWH) for VTE prevention 3
• Manage anticoagulation separately according to procedure-specific bleeding risk:
  • Low-dose aspirin: Generally continue 3
  • Clopidogrel: Hold 5 days before 4
  • Therapeutic LMWH: Hold one dose before 4

Disease Control Balance

• Pomalidomide is used in heavily pretreated patients (median 5 prior regimens) with relapsed/refractory disease 1, 5
• Brief interruptions (3-7 days) are unlikely to significantly impact disease control
• 21.4% of patients continue treatment >1 year, indicating some patients achieve durable responses that can tolerate brief interruptions 1

Common Pitfalls to Avoid

• Do not assume normal blood counts: Always verify CBC before and after the procedure, as hematologic toxicity is nearly universal 1, 2
• Do not forget infection prophylaxis: Grade 3/4 infections occur in 31% of patients on pomalidomide combinations; consider perioperative antibiotic prophylaxis 2
• Do not overlook renal function: Unlike lenalidomide, pomalidomide does not require dose adjustment for renal impairment, but this should still be documented 1