Continue Trilogy (triple therapy) inpatient treatment?

From the Guidelines

Continuing the Trilogy inpatient treatment is recommended for patients with multiple myeloma who are not initially eligible for transplant, with a preference for triplet regimens as standard therapy, but allowing for the use of 2-drug regimens with the option to add a third drug once the patient's performance status improves. This approach is based on the most recent guidelines, including the NCCN guidelines insights: multiple myeloma, version 1.2020 1, which emphasize the importance of triplet regimens for patients with multiple myeloma, but also acknowledge the need for flexibility in treatment approaches for patients who may not be initially eligible for transplant.

Key considerations for continuing Trilogy inpatient treatment include:

• Patient eligibility for transplant, with those not initially eligible potentially starting with a 2-drug regimen and adding a third drug as their performance status improves
• The use of triplet regimens as standard therapy for patients with multiple myeloma, as recommended by the NCCN guidelines 1
• The importance of ongoing assessment and adjustment of treatment parameters to ensure optimal patient outcomes, as discussed in the context of multiple myeloma treatment algorithms 1

In terms of specific treatment approaches, the guidelines suggest that:

• Triplet regimens are preferred for patients with multiple myeloma, but doublet regimens such as pomalidomide and dexamethasone may be considered for elderly frail patients with indolent relapse 1
• Treatment for relapsed multiple myeloma is typically continued until disease progression, with consideration given to increasing the interval between cycles and treatment-free intervals based on tolerability and response 1

From the Research

Inpatient Treatment with Antibiotics

• The treatment of severe infections in patients often requires the use of special-grade antimicrobials, such as linezolid, vancomycin, teicoplanin, tigecycline, imipenem, meropenem, voriconazole, and micafungin 2.
• These antibiotics are commonly used in critically ill patients, and their efficacy can be affected by changes in pharmacodynamics and pharmacokinetics 2.
• Therapeutic drug monitoring (TDM) is essential to optimize the treatment of patients with severe infections, especially those caused by vancomycin-resistant enterococci (VRE) 3.

Optimization of Antibiotic Dosing Regimens

• The optimization of linezolid dosing regimens is crucial for the treatment of VRE infections, and a dosing regimen of 1,200 mg either once daily or as a divided dose every 12 h can achieve target attainments of fAUC24/MICs >80 and >100 3.
• The use of meropenem, a carbapenem antibiotic, requires TDM to optimize therapies and prevent microbial resistance 4.
• The daily dose of meropenem commonly ranges from 3 to 6 g/day, and critically ill patients and those with impaired renal function appear to be the most suitable patients for the application of meropenem TDM 4.

Therapeutic Drug Monitoring

• TDM is essential for the optimal treatment of patients with severe infections, and it can help to maximize clinical outcomes by providing suitable levels of antibiotics and guiding the most appropriate dose regimens 4.
• The measurement status of vancomycin, meropenem, linezolid, and teicoplanin in different laboratories has been reported, and the results show that most laboratories' intra-laboratory %CVs were less than 9% for all drugs 5.
• The use of lyophilized samples is more suitable for therapeutic drug monitoring than frozen samples, as they are more stable and have no obvious differences in matrix effects on most measurement systems 5.