What are the EHA-ESMO guidelines for first-line therapy to treat multiple myeloma (MM)?

Updated: May 11, 2021
  • Author: Dhaval Shah, MD; Chief Editor: Emmanuel C Besa, MD  more...
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EHA-ESMO guideline recommendations for front-line therapy of MM include the following [132] :

  • For fit patients < 70 years without comorbidities, induction therapy (4-6 cycles) followed by conditioning with high-dose melphalan (200 mg/m 2) and autologous stem cell transplantation (ASCT) is the recommended approach.
  • For pre-ASCT induction therapy, daratumumab/bortezomib/thalidomide/dexamethasone (DaraVTD) is the new standard of care. If DaraVTD is not available, bortezomib/thalidomide/dexamethasone (which probably offers the best risk-benefit profile among bortezomib-based triplet regimens) or bortezomib/cyclophosphamide/dexamethasone may be used. Daratumumab/bortezomib/lenalidomide/dexamethasone and isatuximab/bortezomib/lenalidomide/dexamethasone are under clinical investigation and may be standards of care in the near future.
  • Consolidation therapy post-ASCT has not been established to date as standard therapy; 2 cycles of bortezomib/lenalidomide/dexamethasone consolidation has to be considered in patients who received bortezomib/cyclophosphamide/dexamethasone induction, while a tandem ASCT is recommended for patients with genetically defined high-risk disease or in all overall survival benefit, even in high-risk disease, compared with tandem ASCT.
  • Maintenance with lenalidomide is considered the standard of care for all MM patients post-ASCT; bortezomib may be considered for patients with high-risk disease. Ixazomib maintenance offers progression-free survival (PFS) benefit over placebo, but has not been approved by the European Medicines Agency (EMA) or the US Food and Drug Administration (FDA).
  • For patients who are not eligible for ASCT, there are 3 new standards of care: bortezomib/lenalidomide/dexamethasone, daratumumab/bortezomib/melphalan/prednisone and daratumumab/lenalidomide/dexamethasone; if those are not available, bortezomib/lenalidomide/dexamethasone is the preferred option in fit patients; otherwise, lenalidomide/dexamethasone and bortezomib/melphalan/prednisone may be considered.

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