VRD Guidelines for Multiple Myeloma

Introduction to VRD Regimen

The National Comprehensive Cancer Network recommends VRD (bortezomib, lenalidomide, and dexamethasone) as a category 1, preferred regimen for multiple myeloma treatment, particularly as induction therapy for transplant-eligible patients, offering superior progression-free and overall survival compared to doublet regimens 1, 2

The standard VRD regimen consists of bortezomib 1.3 mg/m² subcutaneously on days 1, 8, 15, lenalidomide 25 mg orally on days 1-14, and dexamethasone 20 mg on day of and day after bortezomib, with a cycle repeating every 3 weeks 3, 4

The SWOG S0777 trial demonstrated significantly improved outcomes with VRD compared to Rd, with a median progression-free survival of 43 months vs 30 months and a median overall survival of 75 months vs 64 months 1, 2
The ENDURANCE trial compared VRD to KRd in standard-risk patients, showing similar PFS and VGPR or better rates, but with more peripheral neuropathy in the VRD group 1, 2

For transplant-eligible patients, four to six courses of VRD induction are recommended before proceeding to stem cell collection, with VRD widely used in the United States and becoming standard of care in Europe 5, 6
The American College of Hematology recommends VRD for transplant-ineligible patients, with treatment duration and sequencing depending on patient risk stratification and response to therapy 1, 2

The International Myeloma Society notes that VRD shows differential outcomes based on risk stratification, with standard-risk patients having a median PFS of 76.5 months and 10-year OS of 58%, compared to high-risk patients with a median PFS of 40.3 months and 10-year OS of 29% 1
For patients with acute renal insufficiency, the National Comprehensive Cancer Network suggests bortezomib/cyclophosphamide/dexamethasone may be preferred initially, with consideration to switch to VRD after renal function improves 2

The National Comprehensive Cancer Network recommends subcutaneous rather than IV administration of bortezomib to reduce neuropathy risk, with consideration of dose reduction or schedule modification if neuropathy develops 1, 3, 4

The International Myeloma Working Group criteria should be used for response assessment, with minimal residual disease assessment increasingly important for evaluating depth of response 3, 4