Treatment Regimen for Multiple Myeloma
The prescribed regimen of bortezomib, lenalidomide, and dexamethasone (VRd) represents guideline-concordant triplet therapy for newly diagnosed multiple myeloma, with appropriate supportive care including bisphosphonates, antiviral prophylaxis, and thromboprophylaxis. 1, 2
Primary Induction Therapy Assessment
The core treatment consists of:
Bortezomib 1.3 mg/m² subcutaneously weekly × 16 doses - This proteasome inhibitor is a cornerstone of modern myeloma therapy and subcutaneous administration is preferred to reduce peripheral neuropathy risk 1
Lenalidomide 25 mg daily for 21 days, 7 days off × 4 months - This immunomodulatory agent combined with bortezomib provides superior progression-free survival compared to doublet regimens 1, 3
Dexamethasone (Decmax) 4 mg twice weekly - The dose-reduced dexamethasone approach (versus high-dose) improves tolerability while maintaining efficacy, particularly important for patients over 75 years 1
This VRd triplet regimen achieves complete response rates of 29-44% and median progression-free survival of 35-41 months in transplant-eligible patients 1, 3, 4. For transplant-ineligible patients, 8-12 cycles are typically administered 3, 5.
Supportive Care - Guideline Mandated
Skeletal Protection
- Zoledronic acid 4 mg IV over 15 minutes monthly × 4 months - Bisphosphonates are the only guideline-recommended adjunctive treatment proven to reduce skeletal events, prevent pathologic fractures, and improve quality of life 6, 7. The FDA-approved dosing requires infusion over no less than 15 minutes with adequate hydration 7
Infection Prophylaxis
- Acyclovir (Acivir) 200 mg twice daily - Herpes zoster prophylaxis is mandatory for all patients receiving proteasome inhibitors due to significant reactivation risk 1
Thromboprophylaxis
- Aspirin (Ecosprin) 75 mg daily - Full-dose aspirin is recommended for patients on immunomodulatory therapy (lenalidomide) to prevent venous thromboembolism 1. Higher-risk patients may require therapeutic anticoagulation 1
Gastrointestinal Protection
- Proton pump inhibitor (Sompraz/omeprazole) 40 mg daily - Appropriate given high-dose steroid exposure and potential gastrointestinal toxicity from chemotherapy 1
Nutritional Supplementation
Calcium 500 mg daily and Vitamin D3 60,000 IU weekly - Patients receiving bisphosphonates require calcium supplementation (500 mg daily) and vitamin D (400 IU daily minimum) to prevent hypocalcemia 1, 7. The prescribed weekly high-dose vitamin D3 is appropriate for deficiency correction
Iron supplementation (Livogen) on alternate days - Reasonable for myeloma-associated anemia, though response monitoring is essential 1
B-vitamin supplementation (Nuroday-H, Nurogem-H) - May provide neuropathy prophylaxis benefit, though not specifically guideline-mandated 1
Critical Monitoring Requirements
Renal Function Surveillance
Serum creatinine must be assessed before each zoledronic acid dose 7. For patients with baseline creatinine clearance 30-60 mL/min, zoledronic acid requires dose reduction (3.0-3.5 mg) 7
Lenalidomide requires dose adjustment based on creatinine clearance, with reductions not impacting front-line efficacy 1
Treatment Duration Considerations
The 4-month duration appears appropriate for initial induction in transplant-eligible patients (typically 3-4 cycles) 3, 5, 4
For transplant-ineligible patients, extending VRd to 8-12 cycles followed by lenalidomide maintenance until progression provides superior outcomes 1, 3
High-Risk Disease Modifications
If cytogenetics reveal high-risk features (del(17p), t(4;14), t(14;16), gain 1q, or p53 mutation):
Consider adding daratumumab to VRd (Dara-VRd) for quadruplet therapy, which shows improved outcomes in high-risk patients 3, 5
Bortezomib-containing regimens specifically overcome adverse prognostic impact of t(4;14) and del(17p) 1
After induction, high-risk patients require bortezomib-based maintenance rather than lenalidomide alone 3, 5
Common Pitfalls to Avoid
Do not delay stem cell collection if patient is transplant-eligible - harvest should occur after 3-4 cycles, before prolonged lenalidomide exposure potentially compromises stem cell yield 1
Monitor for peripheral neuropathy - subcutaneous bortezomib reduces but does not eliminate this risk. Dose reduction or switching to carfilzomib may be necessary 1
Ensure adequate hydration before zoledronic acid administration to prevent renal toxicity 7
Screen for secondary malignancies - lenalidomide maintenance increases risk, requiring informed discussion with patients 1