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The optimal treatment of multiple myeloma incorporates the administration of 3 medications, rather than 2, in most transplant-eligible patients, Sagar Lonial, MD, and James R. Berenson, MD, believe. However, clinical trials, including large international studies (FIRST, UPFRONT, and MOVE), have demonstrated efficacy with 2-medication regimens, such as lenalidomide and dexamethasone and bortezomib-based regimens, Sundar Jagannath, MD, notes. On this basis, Jagannath states that it is difficult to only
recommend the use of 3 medications.
In his practice, Jagannath administers bortezomib, lenalidomide, and dexamethasone, noting that giving a proteasome inhibitor, an immunomodulatory agent, and a steroid is important, as multiple myeloma has numerous clones that need to be addressed in newly diagnosed individuals.
Recent data from the international ASPIRE trial evaluating the use of carfilzomib with lenalidomide and dexamethasone has shown impressive results, says Berenson, with a probable survival advantage. The median progression-free survival with the 3-drug carfilzomib regimen was 26.3 months compared with 17.6 months with a 2-drug regimen of lenalidomide and dexamethasone.
In Europe, where it is not possible to give lenalidomide as frontline therapy, Lonial notes that VTD (bortezomib, thalidomide, and dexamethasone) or VCD (bortezomib, cyclophosphamide, and dexamethasone) are commonly administered. Data from the 2014 American Society of Hematology Annual Meeting suggest that VTD was superior to VCD in achieving complete remission.