Recommended Dosages for Multiple Myeloma Treatment
Transplant-Eligible Patients
For transplant-eligible patients, the standard induction regimen is bortezomib 1.3 mg/m² subcutaneously on days 1,8, and 15; lenalidomide 25 mg orally on days 1-14; and dexamethasone 20 mg on the day of and day after bortezomib (or 40 mg on days 1,8,15,22), repeated every 3 weeks for 3-4 cycles. 1
- Following induction, proceed to high-dose melphalan 200 mg/m² IV as the preparative regimen before autologous stem cell transplantation. 1
- For high-risk patients (del 17p, t(4;14), t(14;16), t(14;20), gain 1q, or p53 mutation), consider adding daratumumab 16 mg/kg IV weekly during cycles 1-2, then every 2 weeks during cycles 3-6 to the VRd regimen. 2, 3, 4
Maintenance Therapy Post-Transplant:
- Standard-risk patients: lenalidomide 10-15 mg orally on days 1-21 of each 28-day cycle until progression. 1, 5
- High-risk patients: bortezomib 1.3 mg/m² subcutaneously every 2 weeks plus lenalidomide until progression. 5, 2, 3
Transplant-Ineligible Patients
For transplant-ineligible patients, the recommended triplet regimen is VRd: bortezomib 1.3 mg/m² subcutaneously on days 1,8,15,22; lenalidomide 25 mg orally on days 1-21; and dexamethasone 40 mg orally on days 1,8,15,22, repeated every 28 days for 8-12 cycles. 1
Alternative regimens include:
VMP (Bortezomib/Melphalan/Prednisone): Bortezomib 1.3 mg/m² subcutaneously on days 1,8,15,22; melphalan 9 mg/m² orally on days 1-4; prednisone 60 mg/m² orally on days 1-4, repeated every 35 days. 1
Daratumumab-VMP: Add daratumumab 16 mg/kg IV weekly for cycles 1-9, then every 4 weeks thereafter to the VMP regimen. 1
DRd (Daratumumab/Lenalidomide/Dexamethasone): Daratumumab 16 mg/kg IV weekly during cycles 1-2, every 2 weeks during cycles 3-6, then every 4 weeks; lenalidomide 25 mg orally days 1-21; dexamethasone 40 mg weekly, repeated every 28 days until progression. 2, 3, 4
Dose Modifications for Elderly and Frail Patients
Dexamethasone dosing must be reduced in patients over 75 years: start at 20 mg once weekly rather than 40 mg, with further reduction to 8-20 mg weekly for frail patients based on tolerability. 1
- For patients with creatinine clearance <60 mL/min, reduce lenalidomide dose: 10 mg daily for CrCl 30-60 mL/min; 15 mg every other day for CrCl <30 mL/min. 1
- In patients over 75 years receiving MPT, reduce melphalan to 0.20 mg/kg/day (instead of 0.25 mg/kg/day) and use thalidomide 100 mg daily (instead of 200 mg). 1
Relapsed/Refractory Disease
At first relapse, a triplet regimen is required, with carfilzomib/lenalidomide/dexamethasone (KRd) being a preferred option: carfilzomib 20 mg/m² on cycle 1 days 1-2, then 27 mg/m² on subsequent cycles, IV on days 1,2,8,9,15,16; lenalidomide 25 mg orally days 1-21; dexamethasone 40 mg on days 1,8,15,22, repeated every 28 days. 1
Alternative relapse regimens:
Carfilzomib/dexamethasone (Kd): Carfilzomib 56 mg/m² IV on days 1,2,8,9,15,16 (20 mg/m² on days 1-2 of cycle 1 only); dexamethasone 20 mg on days 1,2,8,9,15,16,22,23, repeated every 28 days. 1
Daratumumab/bortezomib/dexamethasone (DVd): Bortezomib 1.3 mg/m² subcutaneously on days 1,4,8,11 (cycles 1-8); dexamethasone 20 mg orally on days 1,2,4,5,8,9,11,12 (cycles 1-8); daratumumab 16 mg/kg IV weekly during cycles 1-3, every 3 weeks during cycles 4-8, then every 4 weeks. 1
Pomalidomide/dexamethasone: Pomalidomide 4 mg orally on days 1-21 of each 28-day cycle; dexamethasone 40 mg orally on days 1,8,15,22, repeated every 28 days until progression. 6
Critical Dosing Considerations
Thromboprophylaxis is mandatory for all patients receiving immunomodulatory drugs (lenalidomide, thalidomide, pomalidomide): use aspirin 81-325 mg daily for low-risk patients or low-molecular-weight heparin for high-risk patients (prior thrombosis, concurrent erythropoietin, high tumor burden). 1, 5