What would be your approach to initial treatment of a patient with standard-risk myeloma unwilling to undergo autologous stem cell transplant, if practicing in a resource-limited setting?
For non-transplant candidates or patients unwilling to have transplant with standard risk MM, these are my 2 choices:
- RVd: len/velcade/dex: based on the SWOG S077 compared to Rd: Durie et al., PMID 28017406.
- Dara Rd: Daratumumab/Revlimid/dex: based on the MAIA study compared to Rd: Facon et al., PMID 31141632.
Both regimens are easy to give - Velcade and Dara both S.C. and Revlimid Oral.
I give the weekly velcade days 1, 8,15 with revlimid days 1-21 in 28 day cycle.
How do I decide which one: Dara Rd is what I use most frequently given that frequency of Dara decreases with time: weekly x 8 doses (2 months) then q 2 wks x 8 doses (4 mos) then monthly. Easy for the patient's travel.
Patients with diabetes or neuropathy, velcade based may not be the best option.
If co-pay for oral agents is a big problem and the center does not have a case manager/social worker to apply for grants or the patient does not have insurance and the hospital is providing a regimen - then Dara/velcade/dex is a very great option.
If the patient has a problem coming to the center frequently for treatment due to transportation or does not want to be bothered with coming in or requests all oral agents, then IRd: Ixazomib (ninlaro)/Revlimid/dex will be an option too.
Great responses from all these regimens.