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Multiple Myeloma: Closing Considerations for Treatment

Panelists: A. Keith Stewart, MB, ChB, Mayo Clinic; Sagar Lonial, MD, FACP, Emory University School of Medicine; Thomas Martin, MD, UCSF Helen Diller Family; Edward A. Stadtmauer, MD, University of Pennsylvania; Ajai Chari, MD, Mount Sinai Hospital; Amrita Krishnan, MD, FACP, City of Hope Cancer Center
Published: Thursday, Sep 13, 2018



Transcript: 

A. Keith Stewart, MB, ChB: I’d just like to close with a couple of other supportive care issues. Have any of you been using the shingles vaccine now in your patients? Are we still holding off? What’s happening there?

Edward A. Stadtmauer, MD: Just I think it was this week, there was a report of a Merck shingles vaccine that was used particularly in the autologous stem cell transplant setting showing efficacy. And there’s a similar GSK vaccine that has been analyzed and has been reported in abstract form that also shows efficacy and safety in this setting. So, yes, I have now.

A. Keith Stewart, MB, ChB: Those aren’t available yet, are they?

Edward A. Stadtmauer, MD: No, but the Shingrix, or the GSK, is available, and I am starting to recommend this nonlive vaccine for our patients with myeloma.

A. Keith Stewart, MB, ChB: It would certainly be nice not to have to take acyclovir for years on end.

Sagar Lonial, MD, FACP: I guess the question is, can you extrapolate the posttransplant vaccine strategy with somebody who’s actively on therapy, particularly containing dexamethasone?

Edward A. Stadtmauer, MD: Or proteasome inhibitors, right?

Sagar Lonial, MD, FACP: Yes. I think in myeloma, in general, it is a risk factor, but any therapy.

Ajai Chari, MD: And daratumumab is also on-label to have shingle prophylaxis.

Edward A. Stadtmauer, MD: So, I’m not yet ready to stop the oral antiviral prophylaxis even if the patients receive the vaccine. In the clinical trials, they gave the oral prophylaxis for up to 6 months, I believe, after it. So, weighing risks and benefits is not necessarily the end of all VZV (Varicella-zoster virus) prophylaxis.

A. Keith Stewart, MB, ChB: Let’s go quickly into 2 other very quick topics—use of anticoagulants and immune modulators in patients, aspirin or low-molecular weight.

Thomas Martin, MD: Low-risk, aspirin. High-risk, I use a…

A. Keith Stewart, MB, ChB: Antithrombin inhibitor, yes.

Thomas Martin, MD: Yes.

A. Keith Stewart, MB, ChB: Same?

Ajai Chari, MD: Same.

A. Keith Stewart, MB, ChB: Anybody disagree with that? How often are you using the Eliquis (apixaban) or Xarelto (rivaroxaban)?

Amrita Krishnan, MD, FACP: I think for high-risk patients, I would definitely use it if you can get it covered. That’s the big challenge.

Sagar Lonial, MD, FACP: For older patients who have high tumor burden in that first cycle or two where their risk of thrombosis is highest, we may do it for a short time.

A. Keith Stewart, MB, ChB: I saw a study. I can’t remember which. I think it may have been KPd or something, like a 10% DVT rate. Did I miss that, yesterday, right?

Thomas Martin, MD: The carfilzomib combinations have an increased risk of DVT, yes.

Amrita Krishnan, MD, FACP: You think that’s because of the endothelial activation?

Thomas Martin, MD: Probably.

A. Keith Stewart, MB, ChB: Yes. Last one is antibiotics in newly diagnosed patients. There have been some studies suggesting that it’s useful. Ajai, are you using antibiotics in your newly diagnosed patients?

Ajai Chari, MD: Not routinely, but sometimes in the elderly, as was done in the TEAM study from Europe but maybe for the first month.

A. Keith Stewart, MB, ChB: Amrita, I’m going to give you the last words. Antibiotics in your newly diagnosed patients?

Amrita Krishnan, MD, FACP: I’m just using Bactrim (sulfamethoxazole and trimethoprim) for PCP prophylaxis but not…

A. Keith Stewart, MB, ChB: You didn’t believe the Levaquin (levofloxacin) story from…

Amrita Krishnan, MD, FACP: We have a very, how can I put it, fervent ID department that feels very strongly about Levaquin resistance and that was demonstrated in our patient population, so no.

Sagar Lonial, MD, FACP: Bactrim prophylaxis, you may actually get the same effect.

A. Keith Stewart, MB, ChB: All right. Well, we’ve covered a lot, comorbidities there and management of symptoms. This has been a terrific discussion. Before we conclude, I’d like to ask each of our panelists to provide a takeaway from this program, maybe a nugget from their practice that they can convey to the people watching. So, Tom, we’ll let you have your last word.

Thomas Martin, MD: Sure. This is an amazing time for treating patients with myeloma with a plethora of agents. And I would say get familiar with all the regimens, get familiar with daratumumab, pomalidomide, and carfilzomib. Combine 2 of the potent drugs together with dexamethasone and you’ll typically have a good response, and then dose reduce for toxicities and change drugs if you have toxicities. And then I do think that with CAR T cells, we’re all so excited about CAR T cells. In the next 2, 3, 4 years, we’re going to go from the Hyundai to the Cadillac, and I think then we’re going to cure patients with myeloma.

A. Keith Stewart, MB, ChB: It used to be Teslas in California, no? OK, go ahead.

Ajai Chari, MD: I think there’s an amazing number of choices and it keeps increasing. And I think what will be really exciting in the future is to be able to personalize therapy more by genomic stratification, by MRD status. And I think that will be really great for patients. It’s not just one-size-fits-all, which is what it seems like we’re doing right now.

A. Keith Stewart, MB, ChB: Amrita, your takeaways from this meeting?

Amrita Krishnan, MD, FACP: Well, I think to quote one of your colleagues, “If you put 3 myeloma doctors in a room, you get 5 opinions.” And I think that’s a very good thing for patients because it speaks to the number of choices for them and it really is, as Ajai said, individualizing therapy to mitigate toxicity and maximize efficacy.

A. Keith Stewart, MB, ChB: Ed?

Edward A. Stadtmauer, MD: We’ve been so fortunate for our patients to have, over the past decade or so, so many wonderful new therapies that have enhanced their lives, both in terms of quality and in terms of duration. And what I really took from this meeting is that that hasn’t ended, that there still are new approaches, new directions. And my optimism continues to increase.

A. Keith Stewart, MB, ChB: Last word to Sagar.

Sagar Lonial, MD, FACP: Yes, I think with all of these new treatments and approaches, it’s really important that we maintain a consistency of practice. And while each of us can have different flavors on how we do things, we have to build on what has gotten us to where we are today in order not to say, “This is just as good as what we were doing,” but “This is much better than what we were doing.” And that I think is the challenge for all of us.

A. Keith Stewart, MB, ChB: Well, thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us. We hope you found this Peer Exchange® discussion to be both useful and informative.

Transcript Edited for Clarity

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Transcript: 

A. Keith Stewart, MB, ChB: I’d just like to close with a couple of other supportive care issues. Have any of you been using the shingles vaccine now in your patients? Are we still holding off? What’s happening there?

Edward A. Stadtmauer, MD: Just I think it was this week, there was a report of a Merck shingles vaccine that was used particularly in the autologous stem cell transplant setting showing efficacy. And there’s a similar GSK vaccine that has been analyzed and has been reported in abstract form that also shows efficacy and safety in this setting. So, yes, I have now.

A. Keith Stewart, MB, ChB: Those aren’t available yet, are they?

Edward A. Stadtmauer, MD: No, but the Shingrix, or the GSK, is available, and I am starting to recommend this nonlive vaccine for our patients with myeloma.

A. Keith Stewart, MB, ChB: It would certainly be nice not to have to take acyclovir for years on end.

Sagar Lonial, MD, FACP: I guess the question is, can you extrapolate the posttransplant vaccine strategy with somebody who’s actively on therapy, particularly containing dexamethasone?

Edward A. Stadtmauer, MD: Or proteasome inhibitors, right?

Sagar Lonial, MD, FACP: Yes. I think in myeloma, in general, it is a risk factor, but any therapy.

Ajai Chari, MD: And daratumumab is also on-label to have shingle prophylaxis.

Edward A. Stadtmauer, MD: So, I’m not yet ready to stop the oral antiviral prophylaxis even if the patients receive the vaccine. In the clinical trials, they gave the oral prophylaxis for up to 6 months, I believe, after it. So, weighing risks and benefits is not necessarily the end of all VZV (Varicella-zoster virus) prophylaxis.

A. Keith Stewart, MB, ChB: Let’s go quickly into 2 other very quick topics—use of anticoagulants and immune modulators in patients, aspirin or low-molecular weight.

Thomas Martin, MD: Low-risk, aspirin. High-risk, I use a…

A. Keith Stewart, MB, ChB: Antithrombin inhibitor, yes.

Thomas Martin, MD: Yes.

A. Keith Stewart, MB, ChB: Same?

Ajai Chari, MD: Same.

A. Keith Stewart, MB, ChB: Anybody disagree with that? How often are you using the Eliquis (apixaban) or Xarelto (rivaroxaban)?

Amrita Krishnan, MD, FACP: I think for high-risk patients, I would definitely use it if you can get it covered. That’s the big challenge.

Sagar Lonial, MD, FACP: For older patients who have high tumor burden in that first cycle or two where their risk of thrombosis is highest, we may do it for a short time.

A. Keith Stewart, MB, ChB: I saw a study. I can’t remember which. I think it may have been KPd or something, like a 10% DVT rate. Did I miss that, yesterday, right?

Thomas Martin, MD: The carfilzomib combinations have an increased risk of DVT, yes.

Amrita Krishnan, MD, FACP: You think that’s because of the endothelial activation?

Thomas Martin, MD: Probably.

A. Keith Stewart, MB, ChB: Yes. Last one is antibiotics in newly diagnosed patients. There have been some studies suggesting that it’s useful. Ajai, are you using antibiotics in your newly diagnosed patients?

Ajai Chari, MD: Not routinely, but sometimes in the elderly, as was done in the TEAM study from Europe but maybe for the first month.

A. Keith Stewart, MB, ChB: Amrita, I’m going to give you the last words. Antibiotics in your newly diagnosed patients?

Amrita Krishnan, MD, FACP: I’m just using Bactrim (sulfamethoxazole and trimethoprim) for PCP prophylaxis but not…

A. Keith Stewart, MB, ChB: You didn’t believe the Levaquin (levofloxacin) story from…

Amrita Krishnan, MD, FACP: We have a very, how can I put it, fervent ID department that feels very strongly about Levaquin resistance and that was demonstrated in our patient population, so no.

Sagar Lonial, MD, FACP: Bactrim prophylaxis, you may actually get the same effect.

A. Keith Stewart, MB, ChB: All right. Well, we’ve covered a lot, comorbidities there and management of symptoms. This has been a terrific discussion. Before we conclude, I’d like to ask each of our panelists to provide a takeaway from this program, maybe a nugget from their practice that they can convey to the people watching. So, Tom, we’ll let you have your last word.

Thomas Martin, MD: Sure. This is an amazing time for treating patients with myeloma with a plethora of agents. And I would say get familiar with all the regimens, get familiar with daratumumab, pomalidomide, and carfilzomib. Combine 2 of the potent drugs together with dexamethasone and you’ll typically have a good response, and then dose reduce for toxicities and change drugs if you have toxicities. And then I do think that with CAR T cells, we’re all so excited about CAR T cells. In the next 2, 3, 4 years, we’re going to go from the Hyundai to the Cadillac, and I think then we’re going to cure patients with myeloma.

A. Keith Stewart, MB, ChB: It used to be Teslas in California, no? OK, go ahead.

Ajai Chari, MD: I think there’s an amazing number of choices and it keeps increasing. And I think what will be really exciting in the future is to be able to personalize therapy more by genomic stratification, by MRD status. And I think that will be really great for patients. It’s not just one-size-fits-all, which is what it seems like we’re doing right now.

A. Keith Stewart, MB, ChB: Amrita, your takeaways from this meeting?

Amrita Krishnan, MD, FACP: Well, I think to quote one of your colleagues, “If you put 3 myeloma doctors in a room, you get 5 opinions.” And I think that’s a very good thing for patients because it speaks to the number of choices for them and it really is, as Ajai said, individualizing therapy to mitigate toxicity and maximize efficacy.

A. Keith Stewart, MB, ChB: Ed?

Edward A. Stadtmauer, MD: We’ve been so fortunate for our patients to have, over the past decade or so, so many wonderful new therapies that have enhanced their lives, both in terms of quality and in terms of duration. And what I really took from this meeting is that that hasn’t ended, that there still are new approaches, new directions. And my optimism continues to increase.

A. Keith Stewart, MB, ChB: Last word to Sagar.

Sagar Lonial, MD, FACP: Yes, I think with all of these new treatments and approaches, it’s really important that we maintain a consistency of practice. And while each of us can have different flavors on how we do things, we have to build on what has gotten us to where we are today in order not to say, “This is just as good as what we were doing,” but “This is much better than what we were doing.” And that I think is the challenge for all of us.

A. Keith Stewart, MB, ChB: Well, thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us. We hope you found this Peer Exchange® discussion to be both useful and informative.

Transcript Edited for Clarity
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