BCMA-Targeting Bispecifics in Multiple Myeloma: Safety Profile
Expert oncologists briefly review safety profiles of BCMA-targeted bispecifics in multiple myeloma and share practical insight on how to mitigate or address toxicities.
Transcript:
Amrita Krishnan, MD: Let me finish with a few key points again for our community audience about key toxicities. We’ve already talked about CRS [cytokine release syndrome] mitigation strategies, how we mandate regarding inpatient administration. I think the key thing Philippe [Moreau, MD,] did a great job with was infection risks. How are people managing infection risks?
Alfred Garfall, MD: We consider infection to be the major late toxicity that we worry about with teclistamab, so we are giving IVIG [intravenous immunoglobulin] to almost everybody who is responding, who’s going to be on it for longer than a couple of months. Pneumocystis prophylaxis I think is also important, and there were a handful of pneumocystis pneumonia cases, and of course that happens occasionally in relapsed/refractory myeloma, but not that often. I think the rate on the MajesTEC-1 trial was a bit higher than I would’ve expected for a typical patient population with relapsed/refractory myeloma, and pneumocystis prophylaxis is so effective and relatively nontoxic and inexpensive that I think it makes real sense to give these patients pneumocystis prophylaxis.
So IVIG, pneumocystis prophylaxis, of course, herpes zoster prophylaxis is in the FDA prescribing information also. Those are the 3 essential components. Then, the COVID-19 guidance keeps changing, so we were very proactive about giving our patients Evusheld, but Evusheld is no longer available and effective. But anything along those lines to kind of replicate the COVID-19 antibody responses that aren’t going to happen in these patients in response to vaccination. Very proactive therapy for COVID-19 infections that occur with antiviral medications is essential because in MajesTEC-1 there was a large number of patients who passed away from COVID-19. That was probably earlier in the pandemic, but still, I think it speaks to the susceptibility of these patients and the need for proactive management of infection risk. Then when they occur, we need treatment of infections very proactively.
Josh Richter, MD: I think that’s absolutely perfect, we follow the same precautions. The other thing is we’re seeing some late viral reactivations, like CMV [cytomegalovirus], EBV [Epstein-Barr virus], so we’re also doing regular monitoring of CMV PCRs [polymerase chain reaction tests], because all of a sudden these patients will present with disease. I don’t know that it’s clear how often or when, but we’re starting to do this in the commercial setting. The bigger problem is what happens when you have a rising low level PCR with no symptoms. Do you hold, do you not hold? I don’t think any of that is clear.
Alfred Garfall, MD: With teclistamab there is this very idiosyncratic neutropenia that occurs. It can occur early, but it can also occur late in patients who had not had it early on. I agree, CMV has to be considered in those cases, although most often, I think it turns out to be teclistamab-associated neutropenia without a clear underlying cause that is generally very responsive to filgrastim, or short-term dose holds.
Amrita Krishnan, MD: We’ve had that discussion about whether we should do routine, similar to our allos [allogeneic stem cell transplants], CMV monitoring. The challenge given that teclistamab is given until progression is how long are we going to keep checking for CMV? I think we’ve only done it more symptom directed or with other clinical suspicion.
Transcript edited for clarity.
