Relapsed/Refractory Multiple Myeloma: Managing Patients on Bispecific Therapy
Centering discussion on bispecific therapy, panelists consider dosing strategies and adverse event management in relapsed/refractory multiple myeloma.
Transcript:
Andrew P. Dalovisio, MD: Do you [all] feel like you’d be comfortable administering BiTEs [bispecific T-cell engagers] at your location with training? Or is that something you want to kick over to the main campus, have us give it, and then get them back to you?
Kelly Pippin, MD: I would not be comfortable. I think that a lot of times there’s just a lack of comfort with the nurses. We’re always comfortable with what we do often and what we do a lot of. And I think that because this would be a rare administration, I think this would be quite nerve-racking. I wonder if they would be able to grade the CRS [cytokine release syndrome] and understand what to do with the grading and [dose of] tocilizumab and all these kinds of things. I worry that there would be a lot of nervousness.
Ryan P. Griffin, MD: The other challenge we would have in the community setting is not having chemotherapy-certified nurses in the inpatient setting. So that’s a challenge that limits a lot of inpatient therapies.
Kelly Pippin, MD: Absolutely.
Ryan P. Griffin, MD: You’re welcome, Andy. We’ll be getting these patients I think for the most part, which is good. I think knowing the limits of what the community setting can and cannot do is important.
Andrew P. Dalovisio, MD: Sure. I think for now…the concept of them coming to us for ramp-up doses makes perfect sense. The chances of them getting CRS after a ramp-up dose is small.
Ryan P. Griffin, MD: That’s right.
Andrew P. Dalovisio, MD: They can’t offer REMS [risk evaluation and mitigation strategies] training to the infusion room nurses and things like that. I think eventually maybe we could get to a point where they’re comfortable administering because I know at the Covington Clinic, they were certified to give teclistamab. So…some of the smaller infusion rooms can certainly do that. I think for me CRS is a giant boogeyman. Obviously, the severe CRS you can see with CAR T [chimeric antigen receptor T-cell therapy] is scary. But the CRS we’re seeing with bispecifics is mild. And I think when I’m talking to patients or talking to other physicians, I’m like, “Look, you manage neutropenic sepsis in a hospital. To me, that’s 10 times scarier than this.” So I think it’s just demystifying it a little bit. But I think for now… [CROSSTALK]
Ryan P. Griffin, MD: [CROSSTALK]…. You bring up a good point about [all of you] doing the ramp-up dosing and then the maintenance stuff we can handle in the community setting, I think is appropriate.
Andrew P. Dalovisio, MD: Sure.
Thomas Atkinson, MD: Maybe one day…
Andrew P. Dalovisio, MD: But I think that’s a reasonable way to do it, and I think how a lot of centers have been doing it. I think the other thing I’ll talk about is bispecifics. I know I talked about the CRS and the ICANS [immune effector cell-associated neurotoxicity syndrome]. There are a couple of adverse effects you can’t see; you can’t see cytopenias, which can be responsive to transfusions like G-CSF [granulocyte colony-stimulating factor]. I do tend to be aggressive with prophylaxis in these patients because of the infection risk, so antifungal, antibacterial, antiviral prophylaxis, even PJP [Pneumocystis jirovecii prophylaxis], and then IVIG [intravenous immunoglobulin] replacement. So, we can certainly help guide you with that…if these patients do get transitioned into your setting. As far as the ICANS and CRS, there are a couple of resources I’ll tell people about. One is CARTOX. It’s an app you can get on your phone that MD Anderson [Cancer Center] made and you punch in a patient’s vital signs, and it actually gives you a grade therapy. It’s super easy to use. And then mSMART also has a section there now about the management of teclistamab toxicity like ICANS and CRS. It’s very algorithmic and very easy to follow. So, there are some resources for you there if we do get to a point where these are given in the community setting. And I do think that CAR T- [cell therapy] and bispecifics are probably going to move into the solid tumor space by the end of our careers. So, I think we’ll all have to get comfortable managing this, but easing into it slowly makes perfect sense and I told you about those resources we have to look at for the bispecific toxicity management.
Transcript edited for clarity.
