A 75-Year-Old Man With Multiple Myeloma - Episode 5

Treatment Options for Relapsed Multiple Myeloma

April 7, 2021
Jonathan L. Kaufman, MD

Expert in the management of multiple myeloma Jonathan Kaufman, MD, reviews factors to consider when selecting a treatment regimen for patients with relapsed disease.

Jonathan L. Kaufman, MD: When we have a patient with relapsed disease, we factor in several items when considering when to treat. Just because a patient has converted from complete remission to no longer complete remission where we see a small paraprotein, we don't necessarily need to treat that biochemical relapse. We don't want to wait for the patient to have a fracture or significant symptomatic anemia or CRAB [calcium elevation, renal dysfunction, anemia, bone disease] criteria to initiate treatment. Once we see the paraproteins start to rise, we follow the patient very closely and try to institute treatment prior to significant symptomatic disease. Then similar to how we did it upfront, we have several factors when we make the decisions about what to treat. What's the patient's current performance status? What's the risk of the disease? What are the comorbidities? We have 1 additional factor; now we know how the patient tolerated and how the patient responded to prior treatment. Prior tolerance and response is also very important in helping us figure out how to make decisions about what the next treatment is.

We currently have multiple therapies for second-line therapy or for patients with relapsed disease. I would say most importantly, the standard of care for a patient with relapsed disease is 1 to 3 prior lines of therapy; that is going to be a triplet. Whether that triplet is monoclonal antibody plus proteasome inhibitor and dexamethasone, monoclonal antibody plus IMiD [immunomodulatory drug] plus dexamethasone, or proteasome inhibitor plus IMiD and dexamethasone; we have multiple regimens using those backbone therapies. As I described earlier, what the patient had previously, current performance status, and comorbidities will help define which of these multiple 3-drug combinations we'd consider using for patients with relapsed disease.

Transcript edited for clarity.


Case: A 75-Year-Old Man with Multiple Myeloma

Initial Presentation

  • A 75-year-old man presents with worsening fatigue on exertion, pallor, and hip pain
  • PMH: osteoarthritis
  • PE: tired appearing male, poor hand-grip strength, mild tenderness on palpation of the left hip
  • ECOG 2


Clinical workup

  • Hb 9.8 g/dL, corrected calcium 11.9mg/dL, LDH 295U/L, creatinine 1.4mg/dL, albumin 3.7g/dL, CrCl 50mL/min
  • Peripheral blood smear showed rouleaux formation
  • Beta-2 microgloblulin 5.1 mcg/mL, M-protein 2.2 g/dL
  • Lambda free light chains: 0.6 mg/dL, kappa free light chains: 14.3 mg/dL, ratio: 29 (k/l)
  • FISH: hyperdiploid
  • UPEP: M-spike of 400 mg of lambda light chains in 24 hours
  • PET/CT revealed lytic bone lesions in the left hip
  • Bone marrow biopsy shows 58% plasma cells IgG k
  • Diagnosis: ISS and R-ISS, standard risk, stage II MM

Treatment

  • Patient is ineligible for ASCT due to comorbidities
  • Initiated treatment with daratumumab + bortezomib + melphalan + prednisone