Clinical Insights Concerning the Management of Patients with NDMM

EP: 1.Patient Case Introduction: A 65-year-old Female Diagnosed with Transplant-eligible NDMM

EP: 2.An Introduction to Treatment Strategies for Patients with NDMM

EP: 3.Key Trial Data Guiding Treatment Decisions for Patients with NDMM

EP: 4.NDMM Risk-Stratification and Other Factors Informing Treatment Selection

EP: 5.Patient Case Introduction: A 76-year-old Female Diagnosed with Transplant-ineligible NDMM

EP: 6.New Trial Data Informing Optimal Care of Frail Patients with NDMM

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EP: 7.Clinical Insights Concerning the Management of Patients with NDMM

EP: 8.Patient Case Introduction: 66-year-old Male Diagnosed with R/R MM

EP: 9.Determining Who Should Get Quadruplet Vs Triplet Therapy in Multiple Myeloma

Dr. Sagar Lonial: So, Dr. Nooka, let's go back. We heard the landscape from Dr. Kaufman earlier on. How do you make choices about what you're going to do or what you're going to give for a patient based on not being eligible for a transplant, but trying to think through what are you going to give? Are you going to give modified VRD or are you going to give dara-len-dex? How are you going to do that?

Dr. Ajay Nooka: Absolutely. So, the way that we typically don't use a cookie cutter approach to figure out this is the patients that we would be giving the specific regimen to. So good thing is we have options. We have options of using a three drug regimen, dara-len-dex or bortezemib len-dex. We also is have an option of using the quadruplet if somebody is really fit, somebody you feel that can tolerate that regimen. And I use that in scenarios where there are patients at high risk and I'm not able to take them for a transplant. I want to get the best bang for the buck. I give them the quadruplet regimen at a bortezomib based combination specifically for them. But again, having those options is really helpful for us to make the right determination which patient would perceive what.

Dr. Sagar Lonial: So, Dr. Joseph, let's talk about continuation of therapy versus maintenance therapy in the ineligible patient. Are they different?

Dr. Nisha Joseph: I think it depends a little bit on what regimen you're starting with. So, I think as we've said repeatedly, most of us use dara-len-dex, particularly in standard risk patients who are not planning to proceed to transplant. So, for those patients like Jonathan referenced, I tend to peel off the dex and continue them on dara-len. So, I continue the therapy that they're already on. I don't tend to dose reduce if the patients are tolerating those drugs. Like we've referenced before, once we get the response we want, the key is to maintain it. So, you don't want to back off too much. If someone has high risk disease or for other reasons I pick RVD-light, that might be someone that after I achieve a VGPR or better, particularly if they're having toxicity to bortezomib in an older patient, that might be someone where I pull them back to a maintenance type strategy. But I think regardless of what you call it, I think the goal is trying to find some kind of continuous therapy that you can safely deliver to them.

Dr. Sagar Lonial: So, I'm going to wrap this segment up with the question that we probably spend hours debating, which is, do you treat the progression or is there a point where you stop? Particularly, let's focus on the frailer patient. But in general, how do you make that distinction? Quickly.

Dr. Jonathan L. Kauffman: So, my approach for the non-transplant. If we haven't transplanted a patient, we're missing a big effective therapy, then I'm going to treat that patient to progression.

Dr. Nisha Joseph: I'm going to treat that patient until progression.

Dr. Ajay Nooka: I do the same. I'm going to treat the patient until progression. I'm going to peel off the drugs that the patients don't need, continue the lowest amount of drugs that the patient can't tolerate until progression.

Dr. Sagar Lonial: And I might modify just a little. And that is progression or toxicity. I think in the older frailer patient, I knew that's what you all meant. In the older frailer patient, I think sometimes you do have to stop, but you usually let side effects drive that decision. Not arbitrary response or time duration.