Assessing NP Roles in Talquetamab Treatment for Multiple Myeloma

A nurse practitioner discussed how her role plays a vital part in patient care for those undergoing talquetamab treatment for multiple myeloma.

CancerNetwork spoke with Samantha Shenoy, MSN, NP, a nurse practitioner at University of California San Francisco (UCSF) Health, about the role she plays when treating a patient with multiple myeloma who is undergoing treatment with talquetamab-tgvs (Talvey).

Shenoy outlined the importance nurses play in communicating to providers the presence of adverse effects (AEs) related to talquetamab treatment, as well as having responsibility for helping patients manage symptoms. She identified common treatment-related AEs and touched upon cytokine release syndrome (CRS) treatment and preventive measures. Additionally, Shenoy emphasized educating patients on AE management before starting talquetamab to foster awareness.

Furthermore, guidelines for monitoring patients were discussed, with an emphasis on weight loss and taste changes. She subsequently gave her opinion on the future of talquetamab, particularly as a combination therapy. Shenoy concluded by highlighting how AEs can be mitigated, including decreasing the frequency of the drug once patients have achieved a response to therapy.

Q / What is the role of the oncology nurse during talquetamab treatment? Why is this patient-nurse-provider communication so essential during this treatment process?

Shenoy / There is the inpatient component and outpatient component. The patients first receive step-up dosing in the hospital, and during that time, the bedside nurses are critical in monitoring these patients for signs and symptoms of CRS or potential neurotoxicity. They are critical in that regard. Then with talquetamab specifically, because we know it has these very unique GPRC5D-related AEs, nurses can be essential in identifying patients who might be at a higher risk of weight loss.

For example, in my experience, patients can begin to have dry mouth and taste changes even during step-up dosing in the hospital. Nurses can play a key role in communicating to a provider, “Hey, this would be a patient who would benefit from seeing [a dietitian].” [Nurses] are right there at the bedside. I have a handout that I made for our patients. Nurses can help go over that handout with patients. One of the things that we like to do at UCSF is educate patients before AEs happen before they are admitted, or while they are in the hospital having step-up dosing.

If they have not [received] that education, nurses are crucial in spending time with them, talking about the different ways they can manage some of the AEs. In terms of communication with the provider, [nurses relay] if they have CRS, any signs of neurotoxicity, and anything related to GPRC5D-associated AEs. In the same way [nurses help for] inpatient, they can do that for outpatient, too. Our nurses are fantastic, and they bring to the provider awareness about patients who are struggling with some of the taste changes or swallowing.

Q / What are some of the AEs most associated with talquetamab treatment, and how are they managed?

Shenoy / Talquetamab [AEs can be] branched into 2 categories: oral and dermatologic. In terms of oral AEs, there are taste changes, dry mouth, and sometimes difficulty swallowing. Due to these oral AEs, patients may experience weight loss. Patients may voice, especially in the first cycle, that their mouth is sore, and so things like spicy food or citrus can irritate it.

In terms of dermatologic AEs, some of the main things we can see are skin rashes—usually that is in the first cycle—and palmar-plantar desquamation. [There] can be extreme peeling of the palms, the hands, and the soles of the feet. Then [there are] nail changes. Patients can have nail ridging or fragility—most patients’ nails do fall off at some point. There can be separation of the nail plate from the nail bed—onychomadesis—where you can imagine if your nail is starting to separate as you are trying to comb your hair or wearing a wool sweater, your nails are getting caught on that. That can be challenging for patients as well.

Those are the main [AEs] that [come to mind] with talquetamab. Of all those AEs, the ones that are the most challenging in terms of quality of life are the taste changes. It is a broad spectrum. Some patients completely lose their taste. Some patients can only taste sweet things, or for some patients, everything tastes bitter or salty. It is challenging, and it can last for several weeks. I mentioned dry mouth as well. That can be a big one that people do not always talk about, but that can be difficult for patients, especially at night when they are trying to sleep. I have had patients who have had trouble sleeping because their mouth is so dry.

Q / How is CRS managed, and what protocols does your institution have to prevent or treat severe CRS?

Shenoy / We have a protocol that we created for bispecific antibodies specifically at our institution, that we follow for management grade 1 to 4 CRS. We have different interventions. The first sign of CRS is generally fever, but it can manifest in different ways. We give acetaminophen [Tylenol] and tocilizumab [Actemra] with the first fever. If a patient has a second fever, we will give them steroids, like dexamethasone. We like to address it quickly. If someone is having associated hypotension, we will give them fluids and other supportive care for any other signs or symptoms of CRS.

We follow our CRS management algorithm closely. It will outline, “If it is grade 2 [or grade 3, etc], what are interventions?” We nip it in the bud quickly. Usually, it is not an issue.

Q / Are there any neurological effects that are associated with treatment?

Shenoy / There can be neurotoxicity associated with bispecific antibody therapy, but it is rare and it occurs in a small percentage of patients. We, at our institution, do [immune effector cell encephalopathy (ICE)] scores every 12 hours. That is another role that nurses play…doing those ICE scores with patients and watching them closely. Yes, it can occur. Is it an issue? Generally, not with bispecifics. A small percentage of patients experience neurotoxicity.

Q / Are there any guidelines or monitoring parameters that patients and clinicians should abide by when receiving this treatment?

Shenoy / We are generally, as with any other bispecific, looking at laboratory values and vital signs. We are keeping an eye out for any cytopenias, which generally, if we do see that, are going to be in the first few cycles, and then over time it gets better. I would say the biggest difference with talquetamab that we are looking out for, that is different from other bispecifics, is the unique oral and skin AEs we see with the drug. That is where I would say it is very different from teclistamab-cqyv (Tecvayli) or elranatamab-bcmm (Elrexfio).

At every visit, I check in with my patients about how much they are eating and I also monitor their weight. The other dermatologic AEs are manageable. Where we want to be careful is to make sure someone is not having profound weight loss. That is the [main] parameter for [talquetamab]. People might have taste changes, but the question for me is always, “Are you losing weight; is it getting to the point where it is a concerning amount of weight loss?”

Q / Some clinicians have tried different methods of how to overcome taste changes. Have you tried any methods, or do you have any methods for addressing taste changes?

Shenoy / I’ve been working with patients who have been receiving talquetamab for about 4 years now. I had great dietitians who worked with my patients and gave me a lot of the tips that are now in my handout. Within our institution specifically, we worked with patients to find different techniques to address different taste changes or dry mouth.

For example, if a patient was saying something tastes too salty or sweet, we have different recommendations for each patient’s specific taste alterations. [What] I learned throughout this process is we have to address dry mouth because, without saliva, you are not going to be able to taste very well. Some interventions for dry mouth are lozenges, tart candies such as lemon/citrus, and good hydration. There [are many] dry mouth lozenges like XyliMelts.

Colleagues have asked me if they should be consulting nutrition for every patient receiving talquetamab. I don’t think that is necessary, but it is important to consult nutrition for patients who are at high risk of weight loss. I do think these patients specifically should be teamed up with a nutritionist from the very beginning.

In the handout that I made, one of the recommendations is if something tastes like cardboard, have certain spices, etc, at hand when you are eating at the table, or things you can add to it. Alternatively, if something tastes metallic or bitter there are recommendations for that. By having this handout, patients can have tools and options at their disposal, so then when taste changes occur, they will be ready to address some of the challenges that are associated with this treatment. That helps empower patients.

If you can educate patients before they have even started, then they will have the tools they need. I spend time going through the handout with them and I try to tease out what the taste alteration is.

I spoke with a woman named Rebecca Katz, a culinary translator and an expert on the role of food in supporting optimal health, who has worked for years with patients with cancer who have had taste alterations. Something that I learned from her was focusing on food presentation. We often miss how important that can be. When I go to a restaurant and something looks good, my mouth starts to water. I want to eat it because it is plated well; it looks beautiful. One of the things she said was, “I talked to patients about making each meal an event.” Choosing your nicest dishes, laying it out, making it an event, putting garnishes on the side, doing things that make you want to eat the food.

Also, when you do not want to eat and do not have an appetite, do not put a big plate of food in front of you. Do small amounts so that it does not feel overwhelming. Another cool tip I learned from her is when you cannot taste as well, texture takes on a whole new level of importance. For example, think about adding nuts, so even if you cannot taste as well, if things taste crunchy, that can bring some satisfaction to the eating experience. If you cannot taste as well, texture can add some enjoyment. There are all these little tips that can help with the whole eating experience.

Q / What characteristics do these patients have that put them at risk for significant weight loss?

Shenoy / I would say patients who have a low body mass index [BMI], or who have struggled with gaining weight, or who do not have a great appetite to start with. If I know that weight has been an issue with them in the past already, those are the patients I would think about.

Q / Where do you see this agent headed?

Shenoy / Talquetamab is an excellent agent. What I try to tell patients from the beginning is about the efficacy of the drug, because it is impressive. On trial, [many] of these patients already had BCMA-targeted agents. They had several lines of therapy already. I had a patient who had been living with multiple myeloma for 20 years, and she has now been on this drug for about 3 years. When you think about it, that is impressive.

Combinations are the wave of the future with talquetamab. Multiple myeloma is all about combining drugs. One of the trials that I was on, specifically, was the phase 1 TRIMM-2 trial [NCT04108195], where you combine talquetamab with daratumumab [Darzalex]. That is the best way to use these drugs as combination therapies.

Q / Is there anything else that you would want to
highlight from our discussion, or maybe something we did not touch on?

Shenoy / I have seen patients who have had many lines of therapy with limited options left and are now achieving deep and durable responses with talquetamab. I feel passionately about educating patients on management of AEs so that they have a better quality of life. I can imagine how frustrating it is not to be able to taste, to have dry mouth, and to have the skin/nail toxicities associated with talquetamab. The toxicities are manageable for most patients with the interventions I have shared, and I encourage patients to hang in there as their symptoms/AEs will improve over time.

Reference

Dholaria, BR, Weisel K, Mateos MV, et al. Talquetamab (tal) + daratumumab (dara) in patients (pts) with relapsed/refractory multiple myeloma (RRMM): updated TRIMM-2 results. J Clin Oncol. 2023;41(suppl 16). doi:10.1200/JCO.2023.41.16_suppl.8003

The read the full list of guideline recommendations, visit: https://www.cancernetwork.com/view/general-lifestyle-recommendations-for-receiving-talquetamab-in-multiple-myeloma