Thread by @VincentRK

I get a lot of messages and calls everyday on treatment of myeloma from patients. I wish I could respond to each person Here are some frequently asked questions (FAQs) & my answers #medtwitter #myelomaVR #mmsm @mtmdphd @NorthTxMSG

1. Could I have done something to prevent?
No

2. Is myeloma curable?

I don’t consider myeloma a curable disease in the true sense of the word cure. We need to be able to stop therapy completely and the disease doesn’t come back again to consider the disease curable. Read more here nature.com/articles/s4140… @MaurerStats

3. What is your recommended first line treatment?

At present I’m recommending Velcade, Revlimid, Dex (VRd) as the preferred treatment.

If VRd is not available: VTd or VCd

In young high risk patients: I am considering adding Daratumumab to VRd

4. Do all patients need a stem cell transplant?

All eligible patients with newly diagnosed myeloma should have stem cells collected. In most, frontline transplant after 4 cycles of Initial therapy recommended. Selected patients with standard risk can opt for delayed transplant

5. What are the high risk factors in myeloma?

The main ones associated with aggressive biology are: del17, gain 1q, t4;14, t14;16, t14;20, and p53 mutation.
Any 2: Double hit
Any 3 or more: Triple hit

High LDH and high circulating plasma cells also signify high risk biology

6. What do you recommend for maintenance?

Lenalidomide after initial therapy or transplant until progression.

For high risk patients I recommend boretzomib twice a month instead of or in addition to lenalidomide.

7. What’s your preferred regimen for first relapse?

Daratumumab Revlimid Dex (DRd) if I think the myeloma is still sensitive to Revlimid.

Daratumumab Velcade Dex (DVd) or Daratumumab Pomalidomide Dex (DPd) if the myeloma is resistant to Revlimid

8. What dose of Dex?

With every regimen, no more than 40 mg once a week.

Age >70: I prefer 20 mg once a week.

Exceptions is higher dose with first cycle of treatment for cast nephropathy or with VDT PACE.

9. What dose of Velcade?

Once a week subcutaneous.

Exceptions is higher dose with first cycle of treatment for cast nephropathy or with VDT PACE.

10. Are you Ok with once a week carfilzomib?

Yes

11. How long do I have to live?

Hard to say for one patient. In general newly diagnosed patients can expect average survival of 7-10 years or longer but it varies a lot. My post @myelomabeacon is still after many years one of the most read on that site. myelomabeacon.org/news/2012/03/0…

12. What do you recommend for bone prophylaxis: Zometa or Denosumab?

Zometa.
In severe renal failure I’ve used pamidronate. I have not used denosumab so far.

13. What are the most promising treatments likely to be approved shortly?

BCMA directed CAR-T
Belantamab mafodotin (GSKs anti BCMA antibody conjugate)

Promising: Amgen’s BiTe; but may take some time.

14. What about venetoclax?

Be wary. Ok to consider for selected patients with relapsed t11;14 type of myeloma after explaining pros and cons and the fact it’s off label and risky. For more read: @TheLancet thelancet.com/journals/lance…

15. What about Minimal Residual Disease (MRD)?

It’s a good prognostic marker.

Still only a research tool to decide change of treatment. Needs RCTs. I don’t do a bone marrow just to look for MRD in patients who are doing well. We are looking at it as a surrogate for trials

I’ll add more when I get time. Check back. Also if additional questions, please feel free to post. @MyelomaTeacher @IMFjimMYELOMA

I write for @UpToDate. The patient information sections are free to acccess.

Details on criteria, regimens, here: onlinelibrary.wiley.com/doi/pdf/10.100…