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, NP, MSN, a nurse practitioner at the University of California San Francisco 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 prevention measures. Additionally, Shenoy emphasized educating patients on AE management prior to starting talquetamab to foster awareness.

Furthermore, guidelines for monitoring patients were discussed, with an emphasis on weight 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, particularly as doses are reduced with time to optimize responses while reducing toxicities.

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. Starting there, 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 nutrition.” [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 while they are in the hospital getting 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 weight loss, etc. Patients who are at high risk for weight loss in the clinic after they have been discharged, after step-up dosing, [experience AEs that generally happen around cycle 2: some dry skin or nail changes.

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 commonly 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. Patients will complain, 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—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 adopted for bispecific antibody specifically at our institution, that we follow for grade 1 to 4 CRS. We have different interventions. At our institution, the first sign of CRS is generally fever– fever is a cardinal sign. 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 are aggressive in terms of getting tocilizumab with the first fever along with [acetaminophen] and steroids with the second fever, and we follow this grading system. It is a standard thing, there is a chart, and we follow that 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 [neurological effects], but I have not seen it. It is a bispecific antibody, so neurotoxicity has occurred, and it can occur, but it [occurs in] such 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 [results], vital signs. We are keeping an eye out for any neutropenia or cytopenias, which generally, if we do see that, are going to be in the first cycle, 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 degree of taste changes and weight loss. That is where I would say it is very different from teclistamab-cqyv (Tecvayli) or elranatamab-bcmm (Elrexfio).

For example, with any BCMA-targeted bispecific– because of these GPRC5D-related AEs– we are paying attention. In terms of numbers and data, [the most prominent AE is] weight loss. These are monitoring parameters. I ask my patients and check in with them about how much they are eating. The other dermatologic skin toxicity is nail or skin. [These 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 on how to overcome taste changes. Have you tried any methods, or do you have any methods for addressing taste changes?

Shenoy: I was lucky I worked with great dieticians early on. I saw patients on a study almost 4 years ago. I had great dietitians who worked with my patients and gave me a lot of the tips that are now in my handout, which I think you guys have seen. There is [nothing] that we have not done. I have heard of other people attempting prophylactic measures. 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 salty or sweet we have different recommendations for all the 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. [We came] up with interventions for that; dry mouth lozenges, tart candies such as lemon citrus, and good hydration. There [are many] dry mouth melts like Xylimelts.

People have asked me should I be consulting nutrition. I said, absolutely not, because I feel like that is most important for the patients who are at high risk of weight loss– I do think from the very beginning they should be teamed up with a nutritionist.

One of the recommendations [in the handout I made] 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. That helps empower patients. I can have all this ready to go, so then when this happens, I will be ready to address some of the challenges that are associated with this treatment.

If you can educate patients before they have even started, they have the tools that they need. I spend time going through the handout with them and I try to tease out what is the taste alteration. On my handout, if something tastes too salty, this is what you can do; if it tastes metallic or bitter, this is what you can do. I found that patients have appreciated that for the taste changes.

I spoke with a woman named Rebecca Katz, who worked with patients with cancer for years who have had taste alterations. Something that I learned from her was focusing on food presentations. 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 kind of characteristics do these patients have that make them at risk for significant weight loss?

Shenoy: I would say patients who are thin to start off with. They already have a low body mass index [BMI]. Some people I know well, and have always struggled with their weight, or, for whatever reason, their appetite is not great to start with. It is based on BMI that we make that determination. Patients who have had issues with weight in the past, because there is no other drug like this for multiple myeloma, but there are drugs, such as selinexor [Xpovio], that can cause nausea. 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 I talk to them 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. 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 wave of the future. 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 upon?

Shenoy: I feel passionately about [educating patients], because I have seen patients who have had many lines of therapy and are now getting 3, 4, 5 years out of a drug and still going. I feel passionately about the fact that we can just educate patients who are struggling at the beginning [to] hang in there. It is not going to last forever. I can imagine how frustrating it is not to be able to taste, your mouth is dry, and your hands are peeling, but just to know that it is not forever.

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