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Selection of multiple myeloma therapy at third or later relapse

Selection of multiple myeloma therapy at third or later relapse
There is no single standard therapy for relapsed or refractory MM and practice varies widely; as such, we encourage eligible patients to participate in clinical trials. This algorithm illustrates our approach to systemic therapy in patients with third or later relapse of multiple myeloma. Other regimens are available and may be used by other experts. The choice for an individual must take into account expected toxicities, comorbidities, and drug accessibility.

MM: multiple myeloma; BCMA: B cell maturation antigen; Ida-cel: idecabtagene vicleucel; Cilta-cel: ciltacabtagene autoleucel; VDT-PACE: bortezomib, dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide, and etoposide; DCEP: dexamethasone, cyclophosphamide, etoposide, and cisplatin; DPd: daratumumab, pomalidomide, and dexamethasone; IsaPd: isatuximab, pomalidomide, and dexamethasone; EPd: elotuzumab, pomalidomide, and dexamethasone; KPd: carfilzomib, pomalidomide, and dexamethasone; VPd: bortezomib, pomalidomide, and dexamethasone; VCd: bortezomib, cyclophosphamide, and dexamethasone; DKd: daratumumab, carfilzomib, and dexamethasone; IsaKd: isatuximab, carfilzomib, and dexamethasone; SVd: selinexor, bortezomib, and dexamethasone.

* We use the following cutoffs to define refractory and not refractory MM to guide therapy:
  • Refractory: progression within 60 days of exposure to an agent at standard doses
  • Sensitive: progression >60 days from last exposure or progression on minimal therapy (eg, lenalidomide 10 mg or monthly daratumumab)

ΒΆ When selecting a regimen, avoid agents that the MM is refractory to and prioritize regimens that contain two drugs that the MM has not been exposed to. Options include DPd, IsaPd, EPd, KPd, VPd, VCd, DKd, IsaKd, and SVd.

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