How would you approach dose modifications and/or frequency of lenalidomide in patients with advanced renal impairment (eGFR <30)?

Great question - comes up a lot in discussion with community providers.

The dosing is dependent on what your target dose would be.

If normal dosing was 25 mg and CrCl <30 and not on dialysis, then I follow the package insert "15 mg every other day". If the patient tolerates that ok, I increase to 10 mg daily on days 1-21.

If normal dosing was 10-15 mg as in maintenance, then 2.5 mg daily is reasonable.

I think age plays a role as well. Older adults are not able to tolerate the same dose so I lean on the lower dose range for these patients.

Overall, my main message is not to use CKD/AKI as a reason to avoid lenalidomide. Rather, just dose reduce. Start low, go slow, and be sure to increase if possible. Cytopenias are common in this scenario...

The "correct" dose for lenalidomide is a challenge. We know that renal function is a HUGE determinant of lenalidomide exposure (Chen et al., PMID 27351179 & Bridoux et al., PMID 27286995 & Guglieri-López et al., PMID 28039509), but it's NOT the only factor.

We should not forget that the right dose for IMiDs is usually lower than the FDA-approved doses - there is more clear evidence to support this for thalidomide (OPTIMUM) and pomalidomide (Mayo) than for lenalidomide.

In induction, 25 mg of lenalidomide is clearly more toxic than 10 mg, but we don't know that 25 mg is more efficacious. That said, BMS is most grateful for the use of lenalidomide in the maintenance setting, and there we "know" that 10 mg is better than 5 mg (Fenk et al., PMI...