Initial Treatment for Multiple Myeloma

Treatment Approach

The initial treatment for multiple myeloma should include a triplet regimen consisting of bortezomib, lenalidomide, and dexamethasone (VRd) for both transplant-eligible and transplant-ineligible patients, as recommended by the American Society of Clinical Oncology 1
Following induction, patients should proceed to high-dose melphalan (200 mg/m²) with autologous stem cell transplantation, with peripheral blood progenitor cells preferred over bone marrow as the source of stem cells 2
Maintenance therapy with lenalidomide should be continued until progression, with a strength of evidence level of 1, according to the International Myeloma Society 3

For standard risk patients, VRd induction followed by ASCT (if eligible) and lenalidomide maintenance is recommended, with a moderate level of evidence, according to the National Comprehensive Cancer Network 4
For high-risk patients (del 17p, t(14;16), t(14;20)), VRd induction followed by ASCT (if eligible) and bortezomib-based maintenance therapy is preferred, with a high level of evidence, according to the European Society for Medical Oncology 3

Response should be assessed with each treatment cycle using serum and urine electrophoresis, with a complete response requiring <5% plasma cells in bone marrow and negative immunofixation, as defined by the International Myeloma Working Group 2
Whole-body low-dose CT is preferred over conventional skeletal survey for bone assessment, with a moderate level of evidence, according to the American College of Radiology 5

Thromboprophylaxis is essential for patients on immunomodulatory drugs (lenalidomide), with a high level of evidence, according to the American Society of Hematology 4
Bisphosphonates should be administered to reduce skeletal-related events, with a moderate level of evidence, according to the National Osteoporosis Foundation 2

Patient-specific considerations, including age, comorbidities, functional status, and frailty assessment, are essential to determine transplant eligibility, as recommended by the American Society of Clinical Oncology 6
Treatment decisions should account for patient frailty, as frail patients experience higher rates of treatment discontinuation and non-hematologic toxicity, according to the American Society of Clinical Oncology 6