Pharmacists Advancing Immunomodulatory Care in Multiple Myeloma

Multiple myeloma (MM) is a malignant neoplasm of plasma cells that accumulates in the bone marrow and leads to bone destruction, anemia, increased blood calcium, and renal damage due to the secreted monoclonal protein (M-protein).¹ MM is mostly diagnosed among older adults, with a median age of 69 years.² Current frontline treatment options for MM include drugs from multiple drug classes, including proteasome inhibitors, immunomodulatory drugs (IMiDs), corticosteroids, and anti-CD38 monoclonal antibodies.

Immunomodulatory Drugs

IMiDs, including lenalidomide (Revlimid; Celgene), pomalidomide (Pomalyst; Bristol Myers Squibb), and thalidomide (Thalomid; Bristol Myers Squibb), are used in combination with other therapeutics at all stages of MM, and they can also be used as single-agent maintenance treatments.¹ These agents work by inhibiting secretion of proinflammatory cytokines and enhancing cell-mediated immunity by proliferating anti-CD3-stimulated T cells.³

The first IMiD, thalidomide, was developed in 1953 and was originally marketed as an OTC sedative and antiemetic medication for pregnant women. However, it was quickly withdrawn due to severe birth defects and embryo-fetal mortality. Later, thalidomide was found to have anti-inflammatory and antiangiogenic properties and received FDA approval for the treatment of myeloma in 1998.⁴

Newer generation compounds, including lenalidomide and pomalidomide, were developed later in the 2000s.⁴ Currently, all IMiDs are part of the FDA’s Risk Evaluation and Mitigation Strategies (REMS) program. The goal of the program is to prevent embryo-fetal exposure and inform prescribers, patients, and pharmacists on the serious risks and safe-use conditions for these medications.

Barriers to Therapy with IMiDs

Dispensing restrictions can pose a notable barrier to the use of IMiDs.⁵ All IMiDs are managed through the FDA REMS program. As part of the REMS program, there are prescriber, pharmacy, and dispensing requirements. Only prescribers and pharmacies certified with the REMS program can prescribe and dispense the product. Currently, there are only a few pharmacies in the US that are authorized to dispense IMiDs.⁶

In addition to the strict pharmacy and prescriber requirements, patients need to go through extensive testing as well. Female patients of reproductive potential are required to take pregnancy tests before treatment initiation and frequently throughout treatment as well. Female patients are required to use 2 acceptable forms of birth control simultaneously for at least 4 weeks before initiating therapy, while taking it, during any breaks in their treatment, and for at least 4 weeks after stopping the IMiD. Once the pregnancy tests are confirmed negative, an authorization number is generated for the pharmacy to fill the script. Patients can also not receive more than a 28-day supply at a time.

Aside from the challenges with IMiD dispensing restrictions, there are issues with patient adherence as well. In one study of adherence to lenalidomide in older adults with newly diagnosed multiple myeloma, over one-third of the patients were considered to have poor adherence to lenalidomide. The leading reason for the poor adherence was polypharmacy, with a median of 10 medications per patient.⁷ Patients with cancer who have significant comorbidities have a higher occurrence of polypharmacy and an increased risk for drug-drug interactions, adverse drug events, hospitalizations, and mortality.⁸ Pharmacists can close this gap by conducting comprehensive medication reviews and simplifying medication regimens to improve both adherence and safety.

The Role of the Pharmacist in IMiD Therapy

Pharmacists are embedded in many areas within oncology and can have a positive impact on addressing the current gaps in treatment with IMiDs, especially with the optimization of patient access and adherence.

The Fred Hutchinson Cancer Center (FHCC) in Seattle has established a new pharmacist model with its oral chemotherapy monitoring program (OCMP). This program allows pharmacists to prescribe and manage pomalidomide and lenalidomide for patients diagnosed with multiple myeloma. Their team discovered that approximately 240 hours per month were saved by the nursing and physician teams by having pharmacists prescribe IMiDs, obtain REMS authorization, and manage symptoms secondary to therapy.⁹ This is time that can be used to see patients and can allow pharmacists to practice at the top of their licenses. Additionally, patients can benefit from a more standardized process to get their refills.

In a review article looking at the impact of pharmacists on the care of patients with multiple myeloma, researchers discussed how pharmacists help patients achieve their treatment goals. Some of the areas of pharmacist involvement included navigating the REMS program (ie, prescribing, dispensing, and educating about the risks and safe use of IMiDs) and improving medication access by reducing delays in treatment and assisting with financial issues.¹⁰

Additionally, pharmacists play a significant role in addressing polypharmacy by conducting thorough medication reconciliations, minimizing unnecessary medications and doses, and preventing adverse drug reactions. This work is especially valuable for patients with cancer, who often take numerous medications and are at higher risk for complications.

Closing the Gap Between Access and Outcomes

Immunomodulatory drugs remain foundational to MM therapy, yet their clinical benefits are tightly linked to timely access, safe dispensing, and sustained adherence—areas where patients often face significant obstacles. REMS requirements, dispensing limitations, polypharmacy, and complex monitoring schedules can delay therapy initiation and compromise outcomes if not proactively managed. As the use of oral oncolytics continues to expand, these challenges are likely to persist without intentional system-level support.

Pharmacists are uniquely positioned to bridge these gaps in care. Through REMS navigation, medication access coordination, comprehensive medication management, and ongoing patient education, pharmacists help ensure that IMiD therapy is both safe and effective.

REFERENCES

1. Plasma cell neoplasms (including multiple myeloma) treatment (PDQ)–health professional version. National Cancer Institute. Updated April 25, 2025. Accessed December 22, 2025. https://www.cancer.gov/types/myeloma/hp/myeloma-treatment-pdq

2. Cancer stat facts: myeloma. National Cancer Institute Surveillance, Epidemiology, and End Results Program. Accessed December 22, 2025. https://seer.cancer.gov/statfacts/html/mulmy.html

3. Revlimid. Mayo Clinic. August 1, 2025. Accessed December 22, 2025. https://www.mayoclinic.org/drugs-supplements/lenalidomide-oral-route/description/drg-20068352

4. Rehman W, Arfons LM, Lazarus HM. The rise, fall and subsequent triumph of thalidomide: lessons learned in drug development. Ther Adv Hematol. 2011. doi:10.1177/2040620711413165

5. Bristol Myers Squibb REMS program. Bristol Myers Squibb. Accessed December 22, 2025. https://bmsremspatientsafety.com/

6. Lenalidomide, Pomalyst, and Thalomid REMS pharmacy network. Bristol Myers Squibb. Accessed December 22, 2025. https://www.bms.com/assets/bms/us/en-us/pdf/rems-pharmacy-network.pdf

7. Mian H, Fiala M, Wildes TM. Adherence to lenalidomide in older adults with newly diagnosed multiple myeloma. Clin Lymph, Myelo, Leukem. 2020;20(2):98-104.E1. doi:10.1016/j.clml.2019.09.618

8. Turner JP, Shakib S, Singhal N, et al. Prevalence and factors associated with polypharmacy in older people with cancer. Support Care Canc. 2014;22:1727-1734. doi:10.1007/s00520-014-2171-x

9. Indorf A, Kwok M, Jao M, et al. Enhancing multiple myeloma care: implementation of pharmacist-led prescribing of immunomodulatory drugs in an academic medical setting. Clin Lymph, Myelo, Leukem. 2025;25(6):E424-E434. doi:10.1016/j.clml.2025.01.013

10. Park JW, Pereira TT, Rotta I, Lima TM, Aguiar PM, Visacri MB. A scoping review of pharmacists’ clinical activities and impact on the care of patients with multiple myeloma. Int J Clin Pharm. 2024;46:1281-1293. doi:10.1007/s11096-024-01787-x