Which induction therapy regimens are used for primary therapy in patients with multiple myeloma who are not transplant candidates?

Updated: Aug 14, 2019
  • Author: Sara J Grethlein, MD; Chief Editor: Emmanuel C Besa, MD  more...
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Answer

Answer

Therapy typically continues until disease progression. One of the following regimens may be used.

Lenalidomide/dexamethasone:

  • Lenalidomide 25 mg PO daily on days 1-21  plus dexamethasone 40 mg PO daily on days 1, 8, 15, and 22 (20 mg PO daily on days 1,8,15 and 22, for patients over 75 years of age)

Daratumumab, lenalidomide, dexamethasone (DRd):

  • Lenalidomide 25 mg PO daily on days 1-21  plus  dexamethasone 40 mg PO daily on days 1, 8, 15, and 22  plus  daratumumab 16 mg/kg IV weekly in cycles one and two and once every 2 weeks during induction cycles three and four, and every 4 weeks thereafter [2]

Daratumumab/bortezomib/melphalan/prednisone (dara-VMP):

  • Daratumumab 16 mg/kg IV (with dexamethasone 20 mg PO or IV to prevent infusion reactions) once weekly in cycle one, every 3 weeks in cycles two through nine, and every 4 weeks thereafter  plus  bortezomib 1.3 mg/m SC twice weekly on weeks 1, 2, 4, and 5 of cycle one and once weekly on weeks 1, 2, 4, and 5 of cycles 2 onward,  plus   melphalan 9 mg/m PO daily on days 1-4  plus   prednisone 60 mg mg/m  PO daily on days 2-4; 42-d cycle [3]

RVD lite:

  • Lenalidomide 15 mg PO on days 1–21  plus  bortezomib 1.3 mg/m 2 SC weekly on days 1, 8, 15, and 22  plus  dexamethasone 20 mg PO on day of and after bortezomib; 35-day cycle for nine cycles, followed by six cycles of consolidation with lenalidomide and bortezomib [29]

Bortezomib/cyclophosphamide/dexamethasone (CyBorD, VCD); preferred regimen in patients with acute renal insufficiency) [14, 15, 16] :

  • Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11  plus  cyclophosphamide 300 mg/m 2/day PO on days 1, 8, 15, and 22  plus  dexamethasone 40 mg PO daily on days 1-4, 9-12, and 17-20; 28-d cycle for three or four cycles  or
  • Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11  plus  cyclophosphamide 500 mg/m 2/day PO on days 1, 8, and 15  plus  dexamethasone 40 mg PO daily on days 1, 8, and 15; 21-d cycle for three or four cycles  or
  • Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11  plus  cyclophosphamide 900 mg/m 2 IV over 1 h on day 1  plus dexamethasone 40 mg PO daily on days 1 2, 4, 5, 8, 9, 11, and 12; 21-d cycle for three or four cycles

Bortezomib/dexamethasone (preferred regimen in patient with acute renal insufficiency, who may not tolerate triple regimen):

  • Bortezomib 1.3 mg/m 2 IV on days 1, 4, 8, and 11 every 3 wk  plus  dexamethasone 20 mg on the day of and the day after bortezomib [30]

VMP:

  • Bortezomib 1-1.3 mg/m2 on days 1, 4, 8, 11, 22, 25, 29, and 32, followed by a 10-d rest period plus  melphalan 9 mg/m2 PO plus  prednisone 60 mg/m2 PO, both on days 1-4; every 6 wk for four cycles then  a maintenance phase consisting of bortezomib 1-1.3 mg/m2 on days 1, 8, 22, and 29, followed by a 13-d rest period plus  melphalan 9 mg/m2 PO plus  prednisone PO 60 mg/m2; every 5 wk [31]

MPT:

  • Melphalan 0.25 mg/kg PO plus  prednisone 2 mg/kg plus  thalidomide 200 mg PO daily (escalating to 400 mg as tolerated) on days 1-4; every 6 wk [32, 33]

MPR:

  • Lenalidomide 10 mg PO on days 1-21 plus  melphalan 0.18 mg/kg PO on days 1-4 plus dexamethasone 40 mg PO weekly; every 28 d


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