Individualizing Treatments in Multiple Myeloma

Ravi Vij, MD:Management of bone disease in a patient with multiple myeloma is an important thing to keep in consideration. The use of bisphosphonates, either zoledronic acid or pamidronate, is appropriate. Current guidelines recommend that these be given for 2 years post diagnosis, then potentially stopped if the disease is controlled and reinstated when the disease is active once again. So, for a patient whose disease is demanding treatment again, like this 72-year-old individual, I would like to resume a bone-strengthening agent if it had been stopped. The use of Xgeva, or denosumab, has also been given the green light by the FDA recently. That is a drug that does have some advantages in some specific subsets of patients, especially those with renal insufficiency, for whom it is literally free of the side effect of renal damage that often characterizes the use of bisphosphonates. There’s also some data to suggest, from the trial that led to its approval, that it may improve progression-free survival compared with the use of bisphosphonates.

This case illustrates several salient features. I think that it brings forth the dilemma that oncologists face in the choice of treatment regimens, both for frontline and relapsed/refractory disease. I think that with the proliferation of treatment options, that is a good problem to be facing. In this patient, the use of ixazomib (Ninlaro) with lenalidomide (Revlimid) and dexamethasone was an appropriate choice of therapy in my mind. The use of other 3-drug regimens like daratumumab-based, Kyprolis-based regimens may also, in some people’s eyes, have been appropriate. However, the fact is that they are somewhat more inconvenient in administration. So, I think that one certainly is happy with the proliferation of regimens that one has to turn to. The dilemma of choice, often I think, falls on an individual patient. A conversation between the doctor and the patient is key to determine what is appropriate for a given patient. Often it is a more question of how we sequence these regimens than truly a choice between this or this.

Transcript edited for clarity.

CASE: A 72-year-old Caucasian Man With Relapsed Multiple Myeloma

September 2016

• Patient history: At the age of 72, a Caucasian man was diagnosed with multiple myeloma; R-ISS stage I
• Other relevant history includes hypertension and difficulty walking up stairs
• He was treated with lenalidomide/dexamethasone and achieved a VGPR
• Treatment duration was 9 months; patient subsequently discontinued therapy 12 months ago

June 2018

• On routine follow-up, patient complains of increasing problems with fatigue, and has rising levels of M protein
• Laboratory results:
  • Hb, 9.6 g/dL
  • Ca²⁺9.2 mg/dL
  • Creatinine, 0.8 mg/dL
  • M-protein, 3.0 g/dL
  • 30% plasma cells in bone marrow
• Cytogenetics/FISH: del(17p)
• ECOG PS: 2