Third-Line Options for Multiple Myeloma

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There are several options available in the third-line setting for patients with multiple myeloma, according to Jatin J. Shah, MD. These include alkylating agents, pomalidomide-based therapy, carfilzomib-based therapy, retreatment with bortezomib, and panobinostat in combination with bortezomib.

It is important to recognize that some of the clinical trial data may not apply to many patients in the third-line setting, says Shah. For example, data from the ASPIRE and ELOQUENT-2 trials may not be as applicable to patients who have already been exposed to lenalidomide in earlier lines of therapy.

Pomalidomide plus low-dose dexamethasone is an option in the third-line setting following the use of lenalidomide-based therapy in the second-line, says Maria-Victoria Mateos, MD, PhD. However, physicians often prefer to switch drug classes because they feel more comfortable using a different mechanism of action, she adds.

Treatment in the third-line is challenging, since patients have already been exposed to several therapies, says Andrew Spencer, MD. In younger patients, autologous stem cell transplantation with high-dose therapy should be considered, since it can provide an opportunity for retreatment with an immunomodulatory agent or a proteasome inhibitor. In older patients, Spencer prefers an approach that is likely to have less toxicity, such as treatment with alkylating agents and steroids.

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