Case 4: A 77-Year-Old with MM Treated with Bispecifics and Develops Neutropenia
An expert panel offers their initial impressions on the case of a 77-year-old with multiple myeloma treated with a BCMA bispecific antibody who develops neutropenia.
Transcript:
Saad Z. Usmani, MD, MBA, FACP: We’re coming up to the last case here. I’ll hand things over to Anna to talk about this particular patient.
Anna Howard, RN: This is Y.B. She’s a 77-year-old female with stage IIA IgG kappa multiple myeloma [MM]. She was diagnosed in March 1994. She’s had 4 prior lines of therapy, including an IMiD [Immunomodulatory drug], protease inhibitor, anti-CD38 monoclonal antibody, alkylating cytotoxic chemotherapy, and an auto [autologous] stem cell transplant. Pertinent medical comorbidities, in this case, are hypertension, DVT [deep vein thrombosis] in the left leg, coronary artery disease, myocardial infarction, stroke, anemia, recurrent upper respiratory infections, and osteoporosis.
The patient had been receiving daratumumab, pomalidomide, and dexamethasone. She had evidence of progressive disease. The patient started on step-up dosing for commercial teclistamab. She did tolerate this well, with a grade 1 CRS [cytokine release syndrome] after step-up dose 1. The patient does have a history of anemia and neutropenia, which had been previously attributed to her myeloma and her treatment. She did have worsening anemia after step-up dose 1 of the teclistamab. That patient was asymptomatic.
As you’ll see with this chart, on the day that she got her first step-up dose, her hemoglobin was 8.5 g/dL. The day after, it was 7.5 g/dL, and 2 days after her first dose, it was 6.9 g/dL. Regarding neutropenia, on cycle 2, day 15, her ANC [absolute neutrophil count] was 200. The patient was afebrile and asymptotic. Prior to this, her ANC had been within normal limits on her weekly CBCs [complete blood counts]. For the management of the hemoglobin, when it was 6.9 g/dL, she received 1 unit of packed red blood cells without any complications. Her hemoglobin increased to 9 g/dL and it has remained stable with subsequent doses. For the ANC of 200, the patient received 300 µgof subcutaneous filgrastim. The dose of teclistamab was held that day. She was also reeducated on infection precautions and the need to closely monitor for neutropenic fevers.
For follow-up, she continues to have weekly CBCs while receiving her teclistamab. Her hemoglobin has remained greater than 9 since that initial transfusion. The week following, when she received the filgrastim injection, her ANC was up to 1100. She was able to proceed with the teclistamab dose at that time. Her ANC continues to be closely monitored and she remains on teclistamab with a partial response at the last follow-up.
Saad Z. Usmani, MD, MBA, FACP: Thank you, Anna. This case is very unique in so many ways. With the first 3 cases that we talked about, we had relatively young patients who had multiple lines of treatment and many therapies. Here we have someone who is a long-term survivor with MM. This is one of the original patients from the total therapy program created by my mentor, and I took over their case when the myeloma was acting up again. The patient is 30 years older than they were when my mentor took care of them, but really, remarkable longevity in this patient. However, with all the aggressive cytotoxic chemotherapy and tandems that she had received, she continued to have this lingering blood count issue. Interesting in this case is how early the cytopenia started to ensue. I think this had to do with the older age of the patient. What are your thoughts on seeing hematologic toxicities in older myeloma patients? Is this something that you observe across the board as something that you see, regardless of the therapy patients have received?
Carlyn Tan, MD: It’s been relatively common, especially in older patients who have had multiple lines of treatment and multiple autologous stem cell transplants. We’ve definitely seen cytopenias as a big issue, although I think we’ve become more comfortable with it since we see it so often as well, and so supportive transfusions when it’s needed. We rely heavily on G-CSF [filgrastim] injections, as well as TPO [thrombopoietin] agonists, now recently for people with significant thrombocytopenia. We’ve also been using stem cell boosts if there are a small number of stem cells left over to help bridge patients to the next line of treatment or a clinical trial if the limiting issue for eligibility is cytopenias.
Saad Z. Usmani, MD, MBA, FACP: Is this the kind of patient [for whom] you would think about less frequent dosing of the drug? It looks like they’re responding but they’re having adverse effects, so maybe backing off the schedule of weekly dosing a little early might make sense, along with growth factor support.
Carlyn Tan, MD: I agree. I would definitely consider transitioning over to an every other week schedule, or once monthly, as long as they continue with their response and are tolerating the treatment relatively well.
Transcript edited for clarity.
