Tocilizumab Prophylaxis, Caregiver Readiness, and Chair Time Shape Community Bispecific Programs in R/R Myeloma

With teclistamab-cqyv (Tecvayli) plus daratumumab and hyaluronidase-fihj (Darzalex Faspro; Tec-Dara) now holding a category 1 recommendation in the National Comprehensive Cancer Network Guidliness as a second-line option for relapsed/refractory multiple myeloma, community practices are confronting how to deliver bispecific antibodies safely outside the hospital and at a far larger scale than in later lines.^1,2

"We are moving to outpatient treatment. That's the direction we need to go in a community setting, with tocilizumab [Actemra] prophylactically and seeing [these patients] on a daily basis, or [using] remote monitoring," Habte Yimer, MD, chair of hematology/oncology at Texas Oncology–CHRISTUS Trinity Mother Frances Hospital in Tyler, said during a recent OncLive^® Scientific Interchange and Workshop.¹

Yimer led the discussion with co-moderators Tiffiney McMakin, MSN, APRN, FNP-C, AOCNP, a nurse practitioner, and Jill Dickerson, BSN, RN, OCN, manager of nursing services, both of Texas Oncology–Tyler. Faculty included Phillip Chae, MD, of Texas Oncology–Midland Allison Cancer Center in Midland; Kurt Demel, MD, MBA, of HealthPartners in St. Paul, Minnesota; Yan Ji, MD, PhD, MS, of HealthPartners–Regions Hospital in St. Paul; Kimberly Ku, MD, of Illinois CancerCare in Bloomington; Priya Kumar, MBBS, MS, of HealthPartners Medical Group/Regions Hospital in St. Paul; Samir Mazharuddin, MD, of Texas Oncology–Kingwood in Humble; Stan Nabrinsky, MD, of Illinois Cancer Specialists in Elgin; Gordon Ruan, MD, head of the malignant hematology program at HealthPartners Frauenshuh Cancer Center in St. Paul; Robert Schneidewend, DO, MS, of North Memorial Health in Robbinsdale, Minnesota; and Brian Smith, MD, of SSM Health Cancer Care in Bridgeton, Missouri.

The panel worked through 2 cases: 1 on operationalizing bispecific antibodies at a community site and 1 on financial and coverage considerations.¹

How is second-line Tec-Dara reshaping the bispecific landscape?

In the phase 3 MajesTEC-3 trial (NCT05083169), patients with relapsed/refractory multiple myeloma who received 1 to 3 prior lines of therapy were randomly assigned to Tec-Dara (n = 291) or daratumumab and dexamethasone plus either pomalidomide (Pomalyst) or bortezomib (Velcade; n = 296).³ At a median follow-up of 34.5 months, the 36-month progression-free survival (PFS) rate was 83.4% vs 29.7%, respectively (HR, 0.17; 95% CI, 0.12-0.23; P < .001); the 36-month overall survival rate was 83.3% vs 65.0%. These findings helped support the March 2026 FDA approval of the combination for for the treatment of adult patients with relapsed/refractory multiple myeloma who have received at least 1 prior line of therapy.⁴

Grade 3/4 infections occurred in 54.1% of patients in the Tec-Dara arm vs 43.4% in the control arm, whereas cytokine release syndrome (CRS; 60.1%) was predominantly low grade.³ Immune effector cell–associated neurotoxicity syndrome (ICANS) occurred in 1.1% of patients.³

"Infection is a major, a major problem—not CRS, not ICANS. It's infection. People died from infection in this study," Yimer said. “[Patients with multiple myeloma] are already at increased risk of infection, and bispecific T-cell engagers really increase that risk on top of the underlying immune suppression. [These patients need] to be on antiviral prophylactic medication [and] Pneumocystis jirovecii pneumonia prophylaxis with trimethoprim-sulfamethoxazole. If they’re [in a] later line [and] beaten up by transplant and multiple lines of therapy, you could cover them for fungal infection, but I don’t do that in early-line, second-line therapy.”

Yimer cited the larger patient population being treated in the second line vs the fifth line as a crucial reason for optimizing bispecific antibody administration outside of academic settings.⁵

"The number of [patients with] myeloma who you would be treating with bispecific therapy is going to go up 5 times as compared [with] 2025," he said. "Most of these patients in the second-line setting, they're fit, they're in relatively better shape than a fifth-line patient, and they should be able to be treated with bispecific therapy."

Can prophylactic tocilizumab make outpatient step-up dosing routine?

In the phase 2 OPTec/OPTal study (NCT05972135), patients who received prophylactic tocilizumab (n = 43) before the first step-up dose of teclistamab at community sites had a CRS rate of 5%, with all instances at grade 1, and no ICANS.^6,7 In a University of Miami series of 119 patients treated with 4 bispecifics, a single prophylactic dose yielded a CRS rate of 10.1% and an ICANS rate of 5.9%.⁸ Earlier real-world outpatient or hybrid series, in which tocilizumab prophylaxis use was not reported, showed CRS rates of 26.8% (n = 71) and 61% (n = 23).^9,10

"We started to use prophylactic tocilizumab for the myeloma bispecifics because in the NCCN guidelines there's a description of it, so it allows for insurance to cover it," Ruan said. "One of the concerns we've had before is, especially in community patients, sometimes you give them all the education, but they just [may] get overwhelmed and forget to take the dexamethasone, [for example]. If you give them the prophylactic tocilizumab, then at least you know that something was administered to them, so then it gives you a little bit more reassurance."

Yimer reported using prophylaxis in more than 20 patients. "We are really comfortable with it, and [there have been] no significant additional AEs from it, and it's doing what it's supposed to do, keeping our patients safe and keeping the patient outpatient," he said. "It's very reassuring, not only for the patient, but for our providers, who [don't] want to be called multiple times throughout the night. That's very important for the success of this program."

Which patients and programs are ready for outpatient bispecifics?

Faculty agreed that caregiver capacity and health literacy, rather than comorbidity, determine outpatient candidacy. At Texas Oncology–Tyler, a caregiver must attend the nurse teaching session or it is rescheduled, McMakin said. Patients receive a blood pressure cuff, thermometer, and pulse oximeter, record vital signs every 4 to 6 hours while awake, and are seen daily in person or by telemedicine during the first week, a model that parallels one described at OneOncology.¹¹

Infusion chair time, rather than drug administration, emerged as the binding capacity constraint. "The drug is rather simple to administer," Demel said. "It's the monitoring time post-delivery of the agent that really straps our infusion center, and it limits access."

Dickerson noted that a monthly bispecific committee at her practice has trimmed observation to about half of labeled durations, supported by a quick-reference sheet for providers and schedulers that is reprinted on a different color paper after each revision.

Hospital readiness varied widely. Smith, who also flagged poor health literacy in his population and has not yet launched a program, said his affiliated hospital has 1 chemotherapy-certified inpatient nurse.

"The idea of carrying tocilizumab up front, that was almost a nonstarter, at least at first," he said. "Trying to get the hospital itself on board is really tough, and especially doing it in a way that would feel safe…I don't think we're very close, honestly."

In contrast, Dickerson said her team eased the receiving hospital's reservations with a handoff document carrying the patient's last neurologic assessment and vital signs, direct-to-floor admission, a shared calendar of expected admissions, and an email distribution list that reaches hospital billing, pharmacy, charge nurses, and directors.

What unmet needs did were identified?

Staffing, rather than protocol knowledge, emerged as the longer-term limit.

"[The] main issue will be staff training and staff [retention] and staff commitment, nurses primarily, and physicians dedicated to working extended hours and unusual hours to be responsive to the patient's need. [That] is lacking so far," Nabrinsky said. "A 9-to-5 typically will not solve the problem. We can learn all the protocols and tocilizumab and intravenous immunoglobulin [IVIG] prophylaxis, but that's a unique challenge we're facing in the community."

Ruan named expansion to satellite and rural sites as his next challenge, and Ji raised treatment duration as a key topic.

"We're going to use bispecifics earlier and earlier [in treatment courses]," Ji said. "It's still a struggle [to know] how tosequence that, and for bispecifics, do we have to continue until progression, or [is there a] better way we could decide who needs to have a longer vs a shorter treatment duration to avoid the infection risk?"

References

1. Bringing bispecifics home: practical considerations for outpatient and community integration in relapsed/refractory multiple myeloma. An OncLive Scientific Interchange and Workshop. OncLive. September 14, 2026. Accessed November 3, 2026.
2. NCCN Clinical Practice Guidelines in Oncology. Multiple myeloma. Version 5.2026. Accessed July 1, 2026. https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf
3. Costa LJ, Bahlis NJ, Perrot A, et al. Teclistamab plus daratumumab in relapsed or refractory multiple myeloma. N Engl J Med. 2026;394(8):739-752. doi:10.1056/NEJMoa2514663
4. FDA grants third approval under the national priority voucher program. FDA. March 5, 2026. Accessed November 3, 2026. https://www.fda.gov/news-events/press-announcements/fda-grants-third-approval-under-national-priority-voucher-program
5. Nikolaou A, Hogea C, Samyshkin Y, et al. An epidemiology model for estimating the numbers of US patients with multiple myeloma by line of therapy and treatment exposure. Value Health. 2022;25(12):1977-1985. doi:10.1016/j.jval.2022.05.011
6. Forsberg PA, Andorsky D, Rifkin R, et al. Optec/Optal: a phase 2 study to evaluate outpatient (OP), step-up administration of teclistamab (Tec) or talquetamab (Tal) with prophylactic tocilizumab (prophyToci) in patients (pts) with relapsed/refractory multiple myeloma (RRMM). J Clin Oncol. 2026;44(suppl 16):7510. doi:10.1200/JCO.2026.44.16_suppl.7510
7. Prophylactic tocilizumab reduces CRS during outpatient teclistamab, talquetamab step-up in R/R myeloma. OncLive. September 11, 2026. Accessed November 3, 2026. https://www.onclive.com/view/prophylactic-tocilizumab-reduces-crs-in-outpatient-teclistamab-talquetamab-myeloma
8. Kowalski A, Lykon J, Diamond B, et al. Tocilizumab prophylaxis for patients with multiple myeloma treated with bispecific antibodies. Blood Adv. 2025;9(19):4979-4986. doi:10.1182/bloodadvances.2025016911
9. Dhakal B, Ko G, He J, et al. Outcomes of teclistamab (Tec) step-up dosing in outpatient/hybrid settings among a large sample of relapsed refractory multiple myeloma (RRMM) patients treated with Tec. Presented at: 22nd Annual Meeting of the International Myeloma Society; September 17-20, 2025; Toronto, Canada. Abstract PA-023.
10. Abrams J, Barisonek C, Mirsky V, et al. Outcomes of outpatient step-up dosing (SUD) of teclistamab and talquetamab in patients with relapsed/refractory multiple myeloma (RRMM): findings from a large network of community practices in the USA. Presented at: 22nd Annual Meeting of the International Myeloma Society; September 17-20, 2025; Toronto, Canada. Abstract PA-057.
11. Raff L, Wilson R, Murphy R, Jamaleddine A, Bariahtaris N, Roach M. Outpatient care model for teclistamab step-up dosing for the treatment of relapsed or refractory multiple myeloma at OneOncology: insights from a managed network of independent physician-owned community-based oncology practices. J Clin Pathways. 2025;11(6):16-20. doi:10.25270/jcp.2025.11.01