From the Guidelines
Multiple myeloma treatment should prioritize a combination approach with chemotherapy drugs like bortezomib, lenalidomide, or daratumumab, often combined with corticosteroids like dexamethasone, and consideration of high-dose chemotherapy followed by autologous stem cell transplantation for eligible patients, as this approach has been shown to improve survival and quality of life in patients with multiple myeloma 1.
Key Considerations
- The choice of treatment depends on factors such as the patient's age, overall health, disease stage, and genetic features of the myeloma cells.
- Regular monitoring of blood counts, kidney function, and protein levels is essential throughout treatment.
- The International Myeloma Working Group (IMWG) diagnostic criteria and Revised International Staging System should be used to guide diagnosis and staging.
- Updated IMWG response criteria, including definitions for minimal residual disease (MRD) negativity, should be used to assess treatment response.
Treatment Options
- Chemotherapy drugs: bortezomib (Velcade), lenalidomide (Revlimid), daratumumab (Darzalex)
- Corticosteroids: dexamethasone
- High-dose chemotherapy followed by autologous stem cell transplantation for eligible patients
- Maintenance therapy to prevent relapse
Important Factors
- Patient's age and overall health
- Disease stage and genetic features of the myeloma cells
- Regular monitoring of blood counts, kidney function, and protein levels
- Use of IMWG diagnostic criteria and Revised International Staging System
- Assessment of treatment response using updated IMWG response criteria, including MRD negativity 1
From the Research
Overview of Multiple Myeloma
- Multiple myeloma is a hematologic malignancy characterized by the presence of abnormal clonal plasma cells in the bone marrow, with potential for uncontrolled growth causing destructive bone lesions, kidney injury, anemia, and hypercalcemia 2.
- It is diagnosed in an estimated 34,920 people in the US and in approximately 588,161 people worldwide each year 2.
Diagnosis and Staging
- Evaluation of patients with possible multiple myeloma includes measurement of hemoglobin, serum creatinine, serum calcium, and serum free light chain levels; serum protein electrophoresis with immunofixation; 24-hour urine protein electrophoresis; and full-body skeletal imaging with computed tomography, positron emission tomography, or magnetic resonance imaging 2.
- The Revised International Staging System combines data from the serum biomarkers β2 microglobulin, albumin, and lactate dehydrogenase in conjunction with malignant plasma cell genomic features to assess estimated progression-free survival and overall survival 2.
Treatment Options
- Standard first-line (induction) therapy consists of a combination of an injectable proteasome inhibitor (ie, bortezomib), an oral immunomodulatory agent (ie, lenalidomide), and dexamethasone and is associated with median progression-free survival of 41 months 2.
- Lenalidomide is an immunomodulatory drug derived from thalidomide, with anti-inflammatory, immunomodulatory, anti-proliferative, and anti-angiogenic properties 3.
- Pomalidomide, bortezomib, and dexamethasone is a treatment option for patients with relapsed or refractory multiple myeloma who previously received lenalidomide, with significantly improved progression-free survival compared to bortezomib and dexamethasone 4.
Cost-Effectiveness of Treatment Options
- A cost-effectiveness analysis of adding daratumumab or bortezomib to lenalidomide plus dexamethasone for newly diagnosed multiple myeloma found that neither daratumumab nor bortezomib triple therapy were cost-effective compared to lenalidomide plus dexamethasone 5.
- The analysis suggested that further cost-effectiveness analyses that include overall survival data for daratumumab and bortezomib triple therapies are needed to demonstrate an incremental cost-effectiveness ratio in quality-adjusted life-years 5.
Management of Multiple Myeloma
- Induction therapy combined with autologous hematopoietic stem cell transplantation followed by maintenance lenalidomide is standard of care for eligible patients 2.
- The clinical management of lenalidomide-based therapy in patients with newly diagnosed multiple myeloma involves patient selection, lenalidomide dosing, and management of adverse events 6.