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Noopur Raje, MD, Sagar Lonial, MD, and Ann McNeill, RN, APN, describe the use of combination therapy for patients who are newly diagnosed with multiple myeloma. Raje remarks that therapy is selected based on transplant eligibility because some agents may not be appropriate for use in patients who receive autologous stem cell transplants. Raje and Lonial comment that patient eligibility for stem cell transplant depends on performance status.
Historically, the treatment of multiple myeloma involved the use of melphalan-based therapy, note Raje and Lional. However, recent data on combinations without melphalan have shown that lenalidomide/dexamethasone regimens without melphalan were as effective as melphalan-containing regimens; thus, there has been a shift toward the use of bortezomib/dexamethasone or lenalidomide/dexamethasone.
The goal of treatment is to achieve the best possible response, remarks Raje. The type of combination therapy used will depend on the patient’s tolerance for the medications; patients who are eligible for stem cell transplants may be able to tolerate 3-drug combination therapy, for example, with lenalidomide, bortezomib, and dexamethasone (VRD). Lonial remarks that carfilzomib may be used instead of bortezomib with dexamethasone and lenalidomide as part of a 3-drug regimen. McNeill states that at her practice site, the 2 most commonly used induction therapies are the VRD regimen and the bortezomib, cyclophosphamide, and dexamethasone (CyBorD) regimen.
Different strategies are needed for patients who are not eligible for transplant, notes Raje. Studies have shown that continuous treatment with lenalidomide/dexamethasone until progression was beneficial in patients not eligible for transplant.