Multiple Myeloma Treatment Approach

Initial Assessment and Risk Stratification

The International Myeloma Society recommends that all patients with multiple myeloma undergo comprehensive staging including bone marrow examination with FISH for cytogenetic abnormalities, serum and urine protein electrophoresis, and whole-body low-dose CT scan (preferred over conventional skeletal survey) 3, 4
Risk stratification is essential, with high-risk features including del(17p), t(4;14), t(14;16), t(14;20) translocations, and early relapse post-transplant/initial therapy 5, 4
Patient-specific factors, including age, comorbidities, functional status, and frailty assessment, should be evaluated to determine transplant eligibility 1, 6

The National Comprehensive Cancer Network recommends induction therapy consisting of a triplet regimen including bortezomib, lenalidomide, and dexamethasone (VRd) 6
Maintenance therapy with lenalidomide should be continued until disease progression 1, 2
For high-risk patients, consider bortezomib-based maintenance therapy 6, 4

Initial treatment should include at minimum a novel agent (immunomodulatory drug or proteasome inhibitor) and a steroid 1, 3
Preferred triplet regimens include bortezomib, lenalidomide, and dexamethasone (VRd) 1, 2
Continuous therapy is preferred over fixed-duration therapy when using immunomodulatory drug or proteasome inhibitor-based regimens 1, 3

Treatment of relapsed disease should be individualized based on prior treatment response, time to relapse, cytogenetic risk, and patient factors 7, 5
Triplet therapy should be administered on first relapse, though patient tolerance for increased toxicity should be considered 7, 2
Preferred regimens for first relapse include daratumumab-based regimens and carfilzomib/lenalidomide/dexamethasone 2, 8

The National Comprehensive Cancer Network recommends herpes zoster prophylaxis for patients treated with proteasome inhibitors 2, 8
Subcutaneous bortezomib is preferred for patients with pre-existing or high-risk peripheral neuropathy 2, 8
Full-dose aspirin or therapeutic anticoagulation is recommended for patients on immunomodulatory-based therapy 2, 8

Depth of response should be assessed with each treatment cycle using serum and urine protein electrophoresis 3, 4
Once best response is attained or on maintenance therapy, assessment may be less frequent but at minimum every 3 months 3, 4