The Multiple Myeloma TreatmentPyramid: Recommendationsfor ASCT-Eligible Patients1

Access the activity, “Fueling Innovation in Multiple Myeloma: Thoughts From the Chair,” at PeerView.com/CSW40

PRACTICE AID

a Consider harvesting peripheral blood stem cells prior to prolonged exposure to lenalidomide. Both weekly and twice-weekly dosing schemas for bortezomib may be appropriate and acceptable. b Preferred primarily as initial treatment in patients with acute renal insufficiency or those who have no access to bortezomib/lenalidomide/dexamethasone. Consider switching to bortezomib/lenalidomide/dexamethasone after renal function improves. c Carfilzomib can be used once or twice weekly and at different doses. d Can potentially cause cardiac and pulmonary toxicity, especially in elderly patients. e Triplet regimens should be used as the standard therapy for patients with multiple myeloma; however, patients who could not be considered for initiation of treatment with a 3-drug regimen can be started with a 2-drug regimen, with a third drug added once performance status improves. f Treatment option for patients with renal insufficiency and/or peripheral neuropathy. g Daratumumab may interfere with serologic testing and cause false-positive indirect Coombs test. Type and screen should be performed before using daratumumab. h Includes both daratumumab for IV infusion and daratumumab and hyaluronidase-fihj for subcutaneous injection. Daratumumab and hyaluronidase-fihj for subcutaneous injection has different dosing and administration instructions compared with daratumumab for IV infusion. i Generally reserved for the treatment of aggressive multiple myeloma.ASCT: autologous stem cell transplant; NCCN: National Comprehensive Cancer Network.1. NCCN Clinical Practice Guidelines in Oncology. Multiple Myeloma. V.4.2020. https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf. Please consult NCCN guidelines for additional information regarding the regimens listed here, including summary of indications for use.

Other

recommended

regimens

Preferred

regimens

Useful in

certain

circumstancese

Primary Therapy for Newly Diagnosed Transplant Candidates

Exposure to myelotoxic agents (including alkylating agents and nitrosoureas) should be limited to avoidcompromising stem cell reserve prior to stem cell harvest in patients who may be candidates for transplant

Category 2ABortezomib/cyclophosphamide/

dexamethasoneb

Category 1Bortezomib/lenalidomidea/

dexamethasone

Category 2B Ixazomib/lenalidomidea/

dexamethasone

Category 2ACar�lzomibc,d/lenalidomidea/

dexamethasone

Category 1

• Bortezomib/thalidomide/ dexamethasone

Clinical Notes• Selected, but not inclusive of all regimens • Frailty assessment should be considered in older adults • Herpes zoster prophylaxis for patients treated with proteasome inhibitors or daratumumab• Subcutaneous bortezomib is the preferred method of administration• Aspirin (81-325 mg) is recommended with immunomodulator-based therapy; therapeutic anticoagulation is recommended for those at high risk for thrombosis

Category 2A • Bortezomib/doxorubicin/ dexamethasone• Car�lzomib/cyclophosphamide/ dexamethasonef

• Cyclophosphamide/lenalidomidea/ dexamethasone• Daratumumabg,h/bortezomib/ thalidomide/dexamethasone• Dexamethasone/thalidomide/ cisplatin/doxorubicin/ cyclophosphamide/etoposide/ bortezomib (VTD-PACE)i

• Ixazomib/cyclophosphamide/ dexamethasonef