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Although new agents, such as the immunomodulatory agent pomalidomide and the proteasome inhibitor carfilzomib, are widely used in the treatment of patients with relapse refractory multiple myeloma, there is no one treatment regimen that clinicians prefer over another. A patient’s comorbidities are important to consider when selecting one of these drugs because they have different side effect profiles, according to Noopur Raje, MD. He explains that due to the cardiac toxicities associated with carfilzomib, he prefers to treat patients who have cardiovascular-related conditions with pomalidomide. Patients who present with a more aggressive relapse or already existing myelosuppression may benefit from treatment with carfilzomib, which is associated with less myelosuppression. Raje adds that many patients are given both drugs in combination.
Ann McNeill, RN, APN discusses the management of drug toxicities with pomalidomide. She explains that toxicities are managed fairly aggressively, and are therefore unlikely to be the cause of therapy discontinuation. She notes that in most situations, therapy is continued until disease progression occurs.
Sagar Lonial, MD adds that the drug’s dosing and administration are factors to consider. Carfilzomib is given twice-weekly via infusion. Pomalidomide is a once-daily oral medication, which can offer added convenience for patients. Deciding between these 2 drugs can depend on a patient’s history with other similar agents, says Lonial. If a patient has had a good response with a prior immunomodulatory agent, he or she may respond well to pomalidomide. Similarly, a patient who has exhibited sensitivity to a proteasome inhibitor is likely to benefit from carfilzomib.
Lonial notes that patients in the relapse setting who have renal dysfunction can be challenging to treat. Generally, modest dose reduction is warranted in these patients. In older patients who have relapsed, it is common to use either lenalidomide and dexamethasone, or bortezomib and dexamethasone, he says. For patients with end-stage disease, combination therapy with 2 or 3 agents is common.