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

Updated: Jul 11, 2019
  • Author: Sara J Grethlein, MD; Chief Editor: Emmanuel C Besa, MD  more...
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Answer

Answer

One of the following regimens may be used:

  • 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  prednisone60 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 for five cycles [23]

  • 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 [24, 25]

  • Lenalidomide 25 mg PO on days 1-21 plus  dexamethasone 40 mg PO daily on days 1-4, 9-12, and 17-20; every 28 d [18]

  • Bortezomib 1.3 mg/m2 IV on days 1, 4, 8, and 11 every 3 wk plus  dexamethasone 20 mg on the day of and the day after bortezomib [26]

  • Twelve 6-wk cycles of chemotherapy, including melphalan 0.25 mg/kg PO plus  prednisone 2 mg/kg PO for 4 d [27]

  • 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

  • Daratumumab plus lenalidomide plus dexamethasone [28] : Daratumumab 16 mg/kg IV infusion once weekly (weeks 1-8); reduce frequency to q2wk (weeks 9-24) and ultimately q4wk (week 25 and thereafter) until disease progression plus  lenalidomide: 25 mg qd PO on Days 1-21 plus dexamethasone 40 mg PO every 7 d

  • Daratumumab 16 mg/kg IV infusion once weekly (weeks 1-6); reduce frequency to q3wk (weeks 7-54) and ultimately q4wk (week 55 and thereafter) plus bortezomib 1.3 mg/m2 SC twice weekly plus melphalan plus prednisone until disease progression [28]
  • Daratumumab plus bortezomib plus melphalan plus prednisone until disease progression [28]  

The daratumumab/bortezomib/melphalan/prednisone regimen is as follows:

  • Daratumumab 16 mg/kg IV infusion once weekly (weeks 1-6); reduce frequency to q3wk (weeks 7-54) and ultimately q4wk (week 55 and thereafter)  plus
  • Bortezomib 1.3 mg/m 2 SC twice weekly at Weeks 1, 2, 4, and 5 for first 6-week cycle (Cycle 1; 8 doses), followed by once weekly at Weeks 1, 2, 4 and 5 for eight more 6-week cycles (Cycles 2-9; 4 doses per cycle)  plus
  • Melphalan 9 mg/m 2 PO on Days 1-4 of each 6-week cycle (Cycles 1-9)  plus
  • Prednisone: 60 mg/m 2 PO on Days 1-4 of each 6-week cycle (Cycles 1-9)

Alternative treatment recommendations

One of the following may be used:

  • Pegylated liposomal doxorubicin 40 mg/mplus  vincristine 1.4 mg/m2 (maximum, 2.0 mg) as an IV infusion on day 1 plus  reduced-dose dexamethasone 40 mg PO on days 1-4 [29]

  • Vincristine 0.4 mg/day plus  doxorubicin 9 mg/m2/day by continuous infusion on days 1-4 plus  dexamethasone 40 mg/day on days 1-4, 9-12, and 17-20 (odd cycles) and 40 mg/day for 4 d on even cycles; every month [30]

  • Thalidomide may be added to standard regimens in patients with myeloma who are not transplant candidates; a meta-analysis of trials demonstrated improved survival with this approach [31]


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