Role of Novel Subcutaneous Daratumumab in Multiple Myeloma - Episode 5
Ola C. Landgren, MD, PhD: The COVID-19 [coronavirus disease 2019] pandemic has clearly impacted everything, including the care of patients with multiple myeloma. The changes are more practical. We don’t really see that the prognosis is very different for patients with myeloma compared with what we have seen in the general population. That’s very good news. We have been very cautious and careful across the board. All the institutions, we talk to one another all the time. We have been using fewer doses. Instead of giving weekly doses and then dosing every other week, if the regimen has such a dosing schedule, we have tried to move to monthly infusions more quickly to try to skip a few steps. If possible, we have tried to use more oral drugs versus IV [intravenous] or subcutaneous [SQ] drugs. Of course, for newly diagnosed patients or patients who have an active relapse, combination therapy is still much more powerful, so we obviously would prefer that. But then we will go toward a less intense regimen to spare the patients from unnecessary visits.
We have cut back on biopsies; there are no bone marrow biopsies. And also imaging; there are no PET [positron emission tomography] or CT [computed tomography] scans or other types of imaging, unless there is really a strong reason. Typically, in newly diagnosed patients, we would check for MRD [minimal residual disease] status after 6 cycles. Now we would hold off with that. We are waiting for COVID-19 to calm down before we start doing these things again. We also stay away from those combination therapies that are highly cytopenic, and that’s typically in the relapsed/refractory setting. Using all the chemotherapy drugs that would make the patient a candidate for transfusions is not what we want.
The patients would be immunosuppressed, exposed to a lot of risks, and there would be need for platelet and blood transfusions, which we try to save because there is a shortage of blood products.
I think very importantly, we have stopped the entire program for transplantation. This is supported by the ASH [American Society of Hematology] Guidelines that very clearly state no more bone marrow transplants in the setting of COVID-19 for patients with myeloma. This is with the exception of patients who have a lot of aggressive disease, for whom there are no other options. But those patients are few and far between given all the other options we have. ASH says to hold off on the collection of stem cells, so that’s also implemented across the board.
Using modern combination therapy and switching to maintenance, we use carfilzomib, we use bortezomib, we use lenalidomide, we use pomalidomide, we use daratumumab, and we use dexamethasone. We use all those drugs, but we are just cautious and try to minimize the unnecessary visits. We do most of their care, I would say 99% of their care, with telemedicine at the current time, but we are also planning to go back and start seeing patients in the clinic in the coming weeks.
In the current setting of COVID-19, daratumumab is becoming an established standard of care in the newly diagnosed setting in combination with lenalidomide and dexamethasone for nontransplant patients and emerging in combination with RVd [lenalidomide, bortezomib, dexamethasone] or KRd [carfilzomib, lenalidomide, dexamethasone] for transplant candidates. This is already an established standard of care for patients with relapsed disease given CASTOR, POLLUX, and other studies. We already have it in that setting, but the SQ administration of daratumumab would make it an even more attractive regimen. It will increase its use in all these different settings because it’s quicker and easier to give.
Transcript edited for clarity.