What are the selection factors for IMiDs treatment for patients with MMRR?

Drs. Kaufman and Richter outline important considerations for physicians to consider when choosing an IMiD treatment for a patient with MMRR.

Jonathan L. Kaufman, MD: When choosing treatment regimens for patients with relapsed/refractory myeloma, I use 3 factors. One is patient-related factors. What has the patient tolerated before? What is their blood count? What adverse events have they had? Can they come to the clinic regularly and receive infusion therapy? Is this a patient who can reliably take oral medications at home? The next ones we think of are issues related to disease. Is it a rapidly progressive myeloma? Is it slower, lazy? What drugs is the patient refractory to? This leads to the third, which is to understand what the patient had before [been treated with]. If a patient is progressing on one group of drugs, one may want to switch to another group. We put these 3 things together to make our treatment plan.

Joshua Richter, MD: There are so many options for managing myeloma. There are no clear guidelines on how to approach relapsed and refractory patients. For the most part, we choose 3 different modalities to make our decision: patient-related factors, treatment-related factors, and disease-related factors. Patient-related is whether the patient is old or young, fit or frail. Do they have comorbidities? The factors related to the treatment are the therapies they have had before? Did they do well? Did they have a lot of toxicity? With disease-related factors, is their disease bulky? Is it progressing fast? Does it cause organ dysfunction? IMiDS [immunomodulatory drugs] play a big role in this regard. Lenalidomide is one of the key components of our initial treatments, both for induction and maintenance therapy, as well as for early relapse. One of the decisions we make is, as we go into relapse, are you refractory to lenalidomide? The majority of patients in the United States will be treated with lenalidomide initially and will remain on it until progression or intolerance. Once you progressed on lenalidomide, to what dose did you progress? If you were on 10mg maintenance, could we increase that to 25mg and combine that with another drug to give you a lenalidomide triplet? Or were you progressing on 25mg, and now we should move on to a drug like pomalidomide as the IMiD base for the next line of treatment? These are some of the factors that we take into account in trying to provide an individualized approach in the area of ​​relapses and refractories.

There are so many factors we consider including cost. There are many direct and indirect costs for our care. Fortunately, many pharmaceutical companies that make the most expensive oral oncolytics have patient assistance programs to help them. We try to provide the optimal regimen, and if there is a significant financial burden, there are a number of ways to offset it, either through patient assistance programs or through the companies themselves. themselves, either through advocacy groups like the Leukemia & Lymphoma Foundation or the Chronic Disease Fund, or even some private funds will offset that.

This transcript has been edited for clarity.

Martin E. Berry