Multiple Myeloma Which Drugs Are Best for Induction Chemotherapy?

According to Dr. Hoffman, the induction phase typically combines three drugs (a triplet regimen), but sometimes includes four (a quadruplet regimen). See below for a list of the three drug categories that are most commonly included in the induction phase, and the most common drugs that are included in these categories:

Immunomodulators

• Lenalidomide

Proteasome inhibitors

• Velcade (bortezomib)
• Kyprolis (carfilzomib)

Steroids

• Dexamethasone

Lenalidomide is an oral medication–the most commonly used immunomodulator. There are two common options for proteasome inhibitors: Velcade (bortezomib) and Kyprolis (carfilzomib). "Typically you’ll pair an immunomodulator like lenalidomide with one of the proteasome inhibitors like bortezomib or carfilzomib, and that’ll make up two parts of the induction regimen for most patients," said Dr. Hoffman. The one drug that is always incorporated in the induction phase of treatment is a steroid called dexamethasone.

In some cases, more aggressive cancers will also be treated with a fourth kind of drugmonoclonal antibodies. The key drug in this category is called daratumumab.

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Dr. Hoffman acknowledged that the way these drugs are combined may vary based on where you are treated. "Frankly, there’s a lot of debate about the ideal induction for the average patient with multiple myeloma," he said. "The data is not absolutely definitive as to which of these induction approaches is appropriate."

Doctors will consider many variables in these decisions; the wellness of the patient and the subtype of myeloma are two of the most important factors. The genetics of a patient's multiple myeloma cells can be analyzed and placed into categories of low, immediate, or high risk. Even with these factors held constant, however, there is still meaningful variation in how doctors will approach induction.

But Dr. Hoffman is hopeful that ongoing clinical trials will get us closer to a more systematized treatment method. "I think trials…are going to answer these questions. So over subsequent years, patients confronted with these decisions will have real evidence to guide the doctors and improve outcomes," he said.

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