Selection of multiple myeloma therapy at first or second relapse

There is no single standard therapy for relapsed or refractory MM and practice varies widely; as such, we encourage eligible patients to participate in clinical trials. This algorithm illustrates our approach to selecting systemic therapy in most patients with first or second relapse. Other regimens are available and may be used by other experts. The choice for an individual must take into account expected toxicities, comorbidities, drug accessibility, and disease aggressiveness. In addition, all patients are assessed at the time of relapse to determine eligibility for autologous HCT.

MM: Multiple myeloma; DRd: Daratumumab, lenalidomide, and dexamethasone; KRd: Carfilzomib, lenalidomide, and dexamethasone; IRd: Ixazomib, lenalidomide, and dexamethasone; ERd: Elotuzumab, lenalidomide, dexamethasone; DKd: Daratumumab, carfilzomib, and dexamethasone; IsaKd: Isatuximab, carfilzomib, and dexamethasone; DPd: Daratumumab, pomalidomide, and dexamethasone; IsaPd: Isatuximab, pomalidomide, and dexamethasone; KPd: Carfilzomib, pomalidomide, and dexamethasone; VPd: Bortezomib, pomalidomide, and dexamethasone; VCd: Bortezomib, cyclophosphamide, and dexamethasone; SVd: Selinexor, bortezomib, and dexamethasone; DVd: Daratumumab, bortezomib, dexamethasone; HCT: Hematopoietic cell transplantation.
* We use the following cutoffs to define refractory and not refractory MM to guide therapy:

Refractory: progression within 60 days of exposure to an agent at standard doses
Sensitive: progression >60 days from last exposure or progression on minimal therapy (eg, lenalidomide 10 mg or monthly daratumumab)

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Selection of multiple myeloma therapy at first or second relapse