Multiple Myeloma Treatment Regimens

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MULTIPLE MYELOMA TREATMENT REGIMENS

Clinical Trials: The NCCN recommends cancer patient participation in clinical trials as the gold standard for treatment.

Cancer therapy selection, dosing, administration, and the management of related adverse events can be a complex process that should be handled by an experienced healthcare team. Clinicians must choose and verify treatment options based on the individual patient; drug dose modifications and supportive care interventions should be administered accordingly. The cancer treatment regimens below may include both U.S. Food and Drug Administration-approved and unapproved indications/regimens. These regimens are only provided to supplement the latest treatment strategies.

These Guidelines are a work in progress that may be refined as often as new significant data becomes available. The NCCN Guidelines® are a consensus statement of its authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult any NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way.

General treatment note: Exposure to myelotoxic agents—including alkylating agents and nitrosoureas—should be limited to avoid compromising stem-cell reserve prior to stem-cell harvest in patients who may be candidates for transplant.1

(Revised 11/2014)

© 2014 by Haymarket Media, Inc.

Primary Therapy for Transplant Candidates1

Note: All recommendations are Category 2A unless otherwise indicated.

Preferred Regimens

REGIMEN

DOSING

Bortezomib + dexamethasone

(Category 1)2–5*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC,
plus

Days 1–4 (all cycles) and 9–12 (cycles 1 and 2): Dexamethasone 40mg orally daily.

OR

Days 1–2, 4–5, 8–9, and 11–12: Dexamethasone 20mg orally daily.

Repeat cycle every 3 weeks for 3–4 cycles.

Bortezomib + doxorubicin + dexamethasone (Category 1)6–7*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC,
plus

Days 1–4: Doxorubicin 9mg/m2 IV push or continuous IV infusion over 24 hours daily, plus

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily for cycle 1, followed by dexamethasone on days 1–4 for cycles 2–4.

Repeat cycle every 3 weeks for 3–4 cycles.

OR

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC,
plus

Days 1–4: Doxorubicin 9mg/m2 IV push or continuous IV infusion over 24 hours daily, plus

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks for 3–4 cycles.

Bortezomib + thalidomide + dexamethasone (Category 1)4,8–10*†‡

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–21: Thalidomide 50–200mg orally daily at bedtime, plus

Days 1, 2, 4, 5, 8, 9, 11, and 12: Dexamethasone 40mg orally daily.

OR

Days 1–4 and 9–12: Dexamethasone 40mg orally daily.

OR

Days 1–4 (all cycles) and 9–12 (cycles 1 and 2): Dexamethasone 40mg orally daily.

Repeat cycle every 3 weeks for 3–4 cycles.

Lenalidomide + dexamethasone

(Category 1)11,12‡

Days 1–21: Lenalidomide 25mg orally daily, plus

Days 1, 8, 15 and 22: Dexamethasone 40mg orally daily.

OR

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks for 3–4 cycles.

OR

Days 1–28: Lenalidomide 25mg orally daily

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily.

Repeat cycle every 5 weeks for 3–4 cycles.

Bortezomib + lenalidomide + dexamethasone (RVD) (Category 1)13–15*†‡

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–21: Lenalidomide 25mg orally daily, plus

Days 1, 2, 4, 5, 8, 9, 11, and 12: Dexamethasone 40mg orally daily.

OR

Days 1, 8, and 15: Dexamethasone 40mg orally daily.

Repeat cycle every 3 weeks for 3–4 cycles.

Bortezomib + cyclophosphamide + dexamethasone (BCD)16–19*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1, 8, 15, and 22: Cyclophosphamide 300mg/m2/day orally

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks for 3–4 cycles.

OR

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1, 8, and 15: Cyclophosphamide 500mg/m2/day orally

Days 1, 8, and 15: Dexamethasone 40mg orally daily.

Repeat cycle every 3 weeks for 3–4 cycles.

OR

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Day 1: Cyclophosphamide 900mg/m2 IV over 60 minutes

Days 1 2, 4, 5, 8, 9, 11, and 12: Dexamethasone 40mg orally daily.

Repeat cycle every 3 weeks for 3–4 cycles.

Other Regimens

Carfilzomib + Lenalidomide + dexamethasone (CRD)20,21*

Cycle 1:

Days 1 and 2: Carfilzomib 20mg/m2 (maximum 44mg) IV over
2–10 minutes

Days 8, 9, 15, and 16: Carfilzomib 27mg/m2 (maximum 59.4mg) IV over 2–10 minutes

Days 1–21: Lenalidomide 25mg orally daily

Days 1, 8, 15, and 22: Dexamethasone 40mg orally daily.

Cycles 2–7:

Days 1, 2, 8, 9, 15, and 16: Carfilzomib 27mg/m2 (maximum 59.4mg) IV over 2–10 minutes

Days 1–21: Lenalidomide 25mg orally daily

Days 1, 8, 15, and 22: Dexamethasone 40mg orally daily for cycles 2–4, followed by dexamethasone 20mg orally daily for cycles 5–8.

Repeat cycle every 28 days.

OR

Cycle 1:

Days 1 and 2: Carfilzomib 20mg/m2 (maximum 44mg) IV over
2–10 minutes

Days 8, 9, 15, and 16: Carfilzomib 36mg/m2 (maximum 79.2mg) IV over 30 minutes

Days 1–21: Lenalidomide 25mg orally daily

Days 1, 8, 15, and 22: Dexamethasone 40mg orally daily.

Cycles 2–7:

Days 1, 2, 8, 9, 15, and 16: Carfilzomib 36mg/m2 (maximum 79.2mg) IV over 30 minutes

Days 1–21: Lenalidomide 25mg orally daily

Days 1, 8, 15, and 22: Dexamethasone 40mg orally daily for cycles 2–4, followed by dexamethasone 20mg orally daily for cycles 5–8.

Repeat cycle every 28 days.

OR

Cycle 1:

Days 1 and 2: Carfilzomib 20mg/m2 (maximum 44mg) IV over
2–10 minutes

Days 8, 9, 15, and 16: Carfilzomib 36mg/m2 (maximum 79.2mg) IV over 30 minutes

Days 1–21: Lenalidomide 25mg orally daily

Days 1, 2, 8, 9, 15, 16, 22, and 23: Dexamethasone 20mg orally daily.

Cycles 2–7:

Days 1, 2, 8, 9, 15, and 16: Carfilzomib 36mg/m2 (maximum 79.2mg) IV over 30 minutes

Days 1–21: Lenalidomide 25mg orally daily

Days 1, 2, 8, 9, 15, 16, 22, and 23: Dexamethasone 20mg orally daily for cycles 2–4, followed by dexamethasone 10mg orally daily for cycles 5–8.

Repeat cycle every 28 days.

Thalidomide + dexamethasone

(Category 2B)22–25‡

Days 1–28: Thalidomide 50–200mg orally daily at bedtime, plus

Days 1–4 (all cycles), 9–12, and 17–20 (cycles 1 and 3): Dexamethasone 40mg orally daily.

OR

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks for 3–4 cycles.

Dexamethasone

(Category 2B)22,23,26

Day 1–4, 9–12, 17–20: Dexamethasone 20mg/m2 or 40mg orally daily; may consider giving on days 1–4 only starting on cycle 5 and for subsequent cycles.

Repeat cycle every 4–5 weeks for 3–4 cycles.

OR

Days 1–4 (all cycles), 9–12, and 17–20 (cycles 1–2): Dexamethasone 20mg/m2 or 40mg orally daily.

Repeat cycle every 6 weeks for 2–3 cycles.

Liposomal doxorubicin + vincristine + dexamethasone (DVD) (Category 2B)27

Day 1: Pegylated liposomal doxorubicin 40mg/m2 IV over 60 minutes + vincristine 1.4mg/m2 (maximum 2mg) IV over 5–10 minutes

Days 1–4: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks for 3–4 cycles.

Primary Therapy for Non-Transplant Candidates1

Preferred Regimens

Bortezomib + dexamethasone3–5*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC,
plus

Days 1–4 (all cycles) and 9–12 (cycles 1 and 2): Dexamethasone 40mg orally daily.

OR

Days 1–2, 4–5, 8–9, and 11–12: Dexamethasone 20mg orally daily.

Repeat cycle every 3 weeks until maximal response, disease progression, or unacceptable toxicity.

Lenalidomide + low-dose dexamethasone

(Category 1)11‡

Days 1–21: Lenalidomide 25mg orally daily

Days 1, 8, 15, and 22: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Melphalan + prednisone + bortezomib (MPB) (Category 1)28,29*

Days 1–4: Melphalan 9mg/m2 orally daily + prednisone 60mg/m2 orally, plus

Cycles 1–4:

Days 1, 4, 8, 11, 22, 25, 29, and 32: Bortezomib 1.3mg/m2 IV push over 3–5 seconds or SC.

Subsequent Cycles:

Days 1, 8, 22, and 29: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC.

Repeat cycle every 6 weeks until maximal response, disease progression, or unacceptable toxicity.

Melphalan + prednisone + lenalidomide (MPL) (Category 1)30–33‡

Days 1–4: Melphalan 0.18mg/kg orally daily + prednisone 2mg/kg orally daily

Days 1–21: Lenalidomide 10mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

OR

Days 1–4: Melphalan 5mg/m2 orally daily + prednisone 60mg/m2 orally daily

Days 1–21: Lenalidomide 10mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Melphalan + prednisone + thalidomide (MPT) (Category 1)34–39‡

Days 1–4: Melphalan 0.2–0.25mg/kg orally daily + prednisone 2mg/kg or 100mg orally daily

Days 1–42: Thalidomide 50–200mg orally daily at bedtime.

Repeat cycle every 6 weeks until maximal response, disease progression, or unacceptable toxicity.

OR

Days 1–5: Melphalan 0.25mg/kg orally daily + prednisone 1mg/kg orally daily

Days 1–28: Thalidomide 50–200mg orally daily at bedtime.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

OR

Days 1–7: Melphalan 4mg/m2 orally daily + prednisone 40mg/m2 orally daily

Days 1–28: Thalidomide 50–200mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Other Regimens

Dexamethasone

(Category 2B)22,23,26

Day 1–4, 9–12, 17–20: Dexamethasone 20mg/m2 or 40mg orally daily; may consider giving on days 1–4 only starting on cycle 5 and for subsequent cycles.

Repeat cycle every 4–5 weeks until maximal response, disease progression, or unacceptable toxicity.

OR

Days 1–4 (all cycles), 9–12, and 17–20 (cycles 1–2): Dexamethasone 20mg/m2 or 40mg orally daily.

Repeat cycle every 6 weeks until maximal response, disease progression, or unacceptable toxicity.

Liposomal doxorubicin + vincristine + dexamethasone (DVD) (Category 2B)27

Day 1: Pegylated liposomal doxorubicin 40mg/m2 IV over 60 minutes + vincristine 1.4mg/m2 (maximum 2mg) IV over 5–10 minutes

Days 1–4: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Melphalan + prednisone (MP)29,34,36,37,39

Days 1–7: Melphalan 4mg/m2 orally + prednisone 40mg/m2 orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

OR

Days 1–4: Melphalan 0.2–0.25mg/kg orally daily + prednisone 2mg/kg or 100mg orally daily.

Repeat cycle every 4–6 weeks until maximal response, disease progression, or unacceptable toxicity.

OR

Days 1–4: Melphalan 8–9mg/m2 orally daily + prednisone 60mg/m2 orally daily.

Repeat cycle every 4–6 weeks until maximal response, disease progression, or unacceptable toxicity.

Thalidomide + dexamethasone

(Category 2B)22,23,25‡

Days 1–28: Thalidomide 50–200mg orally daily at bedtime, plus

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily.

OR

Days 1–4 (all cycles), 9–12, and 17–20 (cycles 1–4): Dexamethasone 40mg orally daily.

OR

Days 1–4 (all cycles), 9–12, and 17–20 (odd cycles): Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Vincristine + doxorubicin + dexamethasone (VAD) (Category 2B)41

Days 1–4 : Vincristine 0.4mg continuous IV infusion over 24 hours + doxorubicin 9mg/m2 continuous IV infusion over 24 hours daily, plus

Odd Cycles:

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily.

Even Cycles:

Days 1–4: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

OR

Days 1–4: Vincristine 0.4mg IV over 5–10 minutes + doxorubicin 9mg/m2 IV push, plus

Odd Cycles:

Days 1–4, 9–12, and 17–20: Dexamethasone 40mg orally daily.

Even Cycles:

Days 1–4: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Maintenance Therapy1

Preferred Regimens

Bortezomib5,7*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC.

Repeat cycle every 2 weeks for 2 years or until disease progression or unacceptable toxicity.

OR

Days 1, 8, 15, and 22: Bortezomib 1.6mg/m2 IV push over
3–5 seconds or SC.

Repeat cycle every 5 weeks for 6 monthss or until disease progression or unacceptable toxicity.

Lenalidomide


(Category 1)30,42–44‡

Days 1–28: Lenalidomide 10mg orally daily for 3 cycles, followed by 15mg for subsequent cycles.

OR

Days 1–21: Lenalidomide 10mg orally daily.

Repeat cycle every 4 weeks until disease progression or unacceptable toxicity.

Thalidomide

(Category 1)45,46‡

Days 1–28: Thalidomide 50–200mg orally daily at bedtime.

Repeat cycle every 4 weeks until disease progression or unacceptable toxicity.

Other Regimens

Bortezomib + prednisone (Category 2B)47*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–90: Prednisone 50mg orally every other day.

Repeat cycle every 3 months for 3 years or until disease progression or unacceptable toxicity.

Bortezomib + thalidomide (Category 2B)47,48*†‡

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–90: Thalidomide 50–100mg orally daily at bedtime.

Repeat cycle every 3 months for 3 years or until disease progression or unacceptable toxicity.

Interferon alfa

(Category 2B)49,50

Interferon alfa-2b 2–5 million units or 2–5 million units/m2 SC 3 times a week.

Repeat cycle every 4 weeks until disease progression or unacceptable toxicity.

Steroids (Category 2B)51,52

Days 1–4: Dexamethasone 40mg orally daily.

Repeat cycle every 28 days until disease progression or unacceptable toxicity.

OR

Days 1–28: Prednisone 50mg orally every other day.

Repeat cycle every 28 days until disease progression or unacceptable toxicity.

Thalidomide + prednisone (Category 2B)53‡

Days 1–28: Thalidomide 50–200mg orally daily at bedtime + prednisone 50mg orally every other day.

Repeat cycle every 28 days until disease progression or unacceptable toxicity.

Salvage Therapy1

Preferred Regimens

Repeat induction therapy if relapse > 6 months.

Bortezomib

(Category 1)54–56*

Cycles 1–8:

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Repeat cycle every 3 weeks for 8 cycles.

Subsequent Cycles:

Days 1, 8, 15, and 22: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC.

Repeat cycle every 5 weeks for until maximal response, disease progression, or unacceptable toxicity.

Bortezomib + dexamethasone3–5*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1, 2, 4, 5, 8, 9, 11, and 12: Dexamethasone 20mg orally daily.

Repeat cycle every 3 weeks until maximal response, disease progression, or unacceptable toxicity.

Bortezomib + lenalidomide + dexamethasone13–15*†‡

Cycles 1–8:

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–14: Lenalidomide 25mg orally daily, plus

Days 1, 2, 4, 5, 8, 9, 11, and 12: Dexamethasone 40mg orally daily for cycles 1–4, followed by dexamethasone 20mg orally daily for cycles 5–8

OR

Days 1, 8, and 15: Dexamethasone 20–40mg orally daily

Repeat cycle every 3 weeks for 8 cycles.

Subsequent Cycles:

Days 1 and 8: Bortezomib 1.3mg/m2 IV push over 3–5 seconds or SC

Days 1–14: Lenalidomide 15mg orally daily

Days 1, 2, 8, and 9: Dexamethasone 40mg orally daily.

Repeat cycle every 3 weeks until maximal response, disease progression, or unacceptable toxicity.

Bortezomib + liposomal doxorubicin

(Category 1)57*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Day 4: Pegylated liposomal doxorubicin 30mg/m2 IV over 60 minutes.

Repeat cycle every 3 weeks until maximal response, disease progression, or unacceptable toxicity.

Bortezomib + thalidomide + dexamethasone58*†‡

Cycles 1–8:

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–21: Thalidomide 50–200mg orally daily at bedtime

Days 1–4: Dexamethasone 40mg orally daily.

Repeat cycle every 3 weeks for 8 cycles.

Subsequent Cycles:

Days 1, 8, 15, and 22: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–42: Thalidomide 50–200mg orally daily at bedtime

Days 1–4: Dexamethasone 40mg orally daily.

Repeat cycle every 6 weeks until maximal response, disease progression, or unacceptable toxicity.

Carfilzomib59*

Days 1, 2, 8, 9, 15, and 16: Carfilzomib 20mg/m2 (maximum 44mg) IV over 2–10 minutes for cycle 1, followed by carfilzomib 27mg/m2 (maximum 59.4mg) IV over 2–10 minutes for subsequent cycles.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Bortezomib + cyclophosphamide + dexamethasone (BCD)60,61*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1, 8, and 15: Cyclophosphamide 500mg orally daily

Days 1, 2, 4, 5, 8, 9, 11, and 12: Dexamethasone 40mg orally daily.

Repeat cycle every 3 weeks until maximal response, disease progression, or unacceptable toxicity.

OR

Cycles 1–8:

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–21: Cyclophosphamide 50mg orally daily

Days 1, 2, 4, 5, 8, 9, 11, and 12: Dexamethasone 20mg orally daily.

Repeat cycle every 3 weeks for 8 cycles.

Subsequent Cycles:

Days 1, 8, 15, and 22: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Days 1–35: Cyclophosphamide 50mg orally daily

Days 1, 2, 8, 9, 15, 16, 22, and 23: Dexamethasone 20mg orally daily.

Repeat cycle every 5 weeks until maximal response, disease progression, or unacceptable toxicity.

Cyclophosphamide + lenalidomide + dexamethasone (CRD)62‡

Days 1, 8, 15, and 21: Cyclophosphamide 500mg orally daily

Day 1–21: Lenalidomide 25mg orally daily

Day 1–4 and 12–15: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Dexamethasone + cyclophosphamide + etoposide+ cisplatin (DCEP)63–65

Days 1–4: Dexamethasone 40mg/m2 orally daily.

Days 1–4: Cyclophosphamide 400mg/m2 continuous IV infusion over 24 hours daily + etoposide 40mg/m2 continuous IV infusion over
24 hours daily + cisplatin 10–15mg/m2 continuous IV infusion over
24 hours daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Dexamethasone + thalidomide + cisplatin + doxorubicin + cyclophosphamide + etoposide (DT-PACE)66

Days 1–4: Dexamethasone 40mg orally daily

Day 1–28: Thalidomide 50–200mg orally daily at bedtime

Days 1–4: Cyclophosphamide 400mg/m2 continuous IV infusion over 24 hours daily + etoposide 40mg/m2 continuous IV infusion over
24 hours daily + cisplatin 10mg/m2 continuous IV infusion over
24 hours daily + doxorubicin 10mg/m2 continuous IV infusion over
24 hours daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Dexamethasone + thalidomide + cisplatin + doxorubicin + cyclophosphamide + etoposide + bortezomib (VTD-PACE)67*

Induction:

Days 1, 4, 8, and 11: Bortezomib 1mg/m2 IV push over 3–5 seconds or SC

Day 4–7: Thalidomide 50–200mg orally daily at bedtime

Days 4–7: Dexamethasone 40mg orally daily

Days 4–7: Cyclophosphamide 400mg/m2 continuous IV infusion over 24 hours daily + etoposide 40mg/m2 continuous IV infusion over
24 hours daily + cisplatin 10mg/m2 continuous IV infusion over
24 hours daily + doxorubicin 10mg/m2 continuous IV infusion over
24 hours daily.

Consolidation:

Cycle 1: Beginning 6 weeks–4 months after last transplant:

Days 1, 4, 8, and 11: Bortezomib 1mg/m2 IV push over 3–5 seconds or SC

Day 1–4: Thalidomide 50–200mg orally daily at bedtime

Days 1–4: Dexamethasone 40mg orally daily

Days 1–4: Cyclophosphamide 300mg/m2 continuous IV infusion over 24 hours daily + etoposide 30mg/m2 continuous IV infusion over
24 hours daily + cisplatin 7.5mg/m2 continuous IV infusion over
24 hours daily + doxorubicin 7.5mg/m2 continuous IV infusion over
24 hours daily.

Cycle 2: Beginning 2 – 4 months after cycle 1:

Days 1, 4, 8, and 11: Bortezomib 1mg/m2 IV push over 3–5 seconds or SC

Day 1–4: Thalidomide 50–200mg orally daily at bedtime

Days 1–4: Dexamethasone 40mg orally daily

Days 4–7: Cyclophosphamide 300mg/m2 continuous IV infusion over 24 hours daily + etoposide 30mg/m2 continuous IV infusion over
24 hours daily + cisplatin 7.5mg/m2 continuous IV infusion over
24 hours daily + doxorubicin 7.5mg/m2 continuous IV infusion over
24 hours daily.

High-dose cyclophosphamide68

Days 1–4: Cyclophosphamide 600mg/m2 IV over 60 minutes.

Repeat cycle every 4 weeks for 2 cycles, then every 3 months until maximal response, disease progression, or unacceptable toxicity.

Lenalidomide + dexamethasone

(Category 1)69,70‡

Days 1–21: Lenalidomide 25mg orally daily

Days 1–4 (all cycles), 9–12, and 17–20 (cycles 1–4): Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Pomalidomide + dexamethasone71

Days 1–21: Pomalidomide 4mg orally daily

Days 1, 8, 15, and 22: Dexamethasone 40mg (age ≤75 years) or 20mg (age >75 years) orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Thalidomide + dexamethasone72–74‡

Days 1–28: Thalidomide 50–200mg orally daily at bedtime, plus

Days 1–4 (all cycles), 9–12, and 17–20 (cycle 1): Dexamethasone 20mg/m2 or 40mg orally daily.

OR

Days 1–4: Dexamethasone 20mg/m2 or 40mg orally daily.

OR

Days 1–5 (all cycles) and 15–19 (until response): Dexamethasone 20mg/m2 or 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Other Regimens

Bendamustine75,76

Days 1 and 2: Bendamustine 80–150mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

Bortezomib + vorinostat77,78*

Days 1, 4, 8, and 11: Bortezomib 1.3mg/m2 IV push over
3–5 seconds or SC

Day 1–14: Vorinostat 400mg orally daily.

Repeat cycle every 3 weeks until maximal response, disease progression, or unacceptable toxicity.

Lenalidomide + bendamustine + dexamethasone (BLD)79‡

Days 1 and 2: Bendamustine 75mg/m2 IV over 30 minutes

Days 1–21: Lenalidomide 10mg orally daily

Days 1, 8, 15, and 22: Dexamethasone 40mg orally daily.

Repeat cycle every 4 weeks until maximal response, disease progression, or unacceptable toxicity.

* Recommended herpes zoster prophylaxis for patients treated with bortezomib and carfilzomib.

† Consider using subcutaneous bortezomib for patients with pre-existing high-risk peripheral neuropathy.

‡ Prophylactic anticoagulation recommended for patients receiving thalidomide-based therapy or lenalidomide with dexamethasone.

References

1. NCCN Clinical Practice Guidelines in Oncology™. Multiple Myeloma. v 2.2015. Available at: http://www.nccn.org/ professionals/physician_gls/pdf/myeloma.pdf. Accessed November 5, 2014.

2. Avet-Loiseau H, Leleu X, Roussel M, et al. Bortezomib plus dexamethasone induction improves outcome of patients with t(4;14) myeloma but not outcome of patients with del(17p). J Clin Oncol. 2010;28:4630–4634.

3. Harousseau JL, Attal M, Avet-Loiseau H, et al. Bortezomib plus dexamethasone is superior to vincristine plus doxorubicin plus dexamethasone as induction treatment prior to autologous stem cell transplantation in newly diagnosed multiple myeloma: results of the IFM 2005-01 phase III trial. J Clin Oncol. 2010; 28:4621–4629.

4. Moreau P, Avet-Loiseau H, Falcon T, et al. Bortezomib plus dexamethasone versus reduced-dose bortezomib, thalidomide plus dexamethasone as induction treatment before autologous stem cell transplantation in newly diagnosed multiple myeloma. Blood. 2011;118(22):5752–5758.

5. Niesvizky R, Flinn IW, Rifkin R, et al. Efficacy and safety of three bortezomib-based combinations in elderly, newly diagnosed multiple myeloma patients: results from all randomized patients in the community-based, phase 3b, UPFRONT study. Blood. 2011;118:Abstract 478.

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Hematologic Cancer Drug Monographs

Leukemias, Lymphomas, And Other Hematologic Cancers

Adcetris Adriamycin Adriamycin solution
Alkeran Alkeran for injection Aredia
Arranon Arzerra Bexxar
Bicnu Busulfex Campath
Ceenu Cerubidine Clolar
Cytarabine Dacogen Depocyt
Doxil DTIC-Dome Elspar
Fludara Folotyn Gleevec
Hydrea Idamycin Idamycin PFS
Intron A Intron A Soln Intron A Soln Multidose Pens
Istodax Leukeran Leustatin
Matulane Methotrexate for injection Methotrexate injection
Mustargen Myleran Mylotarg
Novantrone Oforta Oncaspar
Ontak Pentostatin Purinethol
Revlimid Rituxan Sprycel
Tabloid Targretin Targretin gel
Tasigna Thalomid Treanda
Trexall Trisenox Uvadex
Velcade Vesanoid Vidaza
Vinblastine for injection Vinblastine injection Vincasar PFS
Vumon Zevalin Zolinza
Zometa


Data provided by the Monthly Prescribing Reference (MPR) Hematology/Oncology Edition.
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