Pharmacists Weigh Real-World Challenges of Bispecific Antibodies in Multiple Myeloma

Bispecific antibodies are rapidly reshaping the treatment landscape for relapsed/refractory multiple myeloma (RR MM). This paradigm shift means pharmacists are increasingly navigating complex decisions extending well beyond efficacy alone. At a Pharmacy Times Clinical Forum held on December 7 during the 67th American Society of Hematology Annual Meeting and Exposition in Orlando, Florida, oncology pharmacists from a variety of settings gathered to explore the real-world challenges surrounding bispecific antibody therapies.^1,2

The expert panelists, spanning academic, community, and hybrid pharmacy practices, discussed key factors in optimizing bispecific antibody treatment, including patient selection, toxicity management, sequencing, and transitions of care. Major points of conversation included the growing use of bispecific antibodies in earlier lines of therapy, differing approaches to cytokine release syndrome (CRS) prophylaxis, and persistent gaps in community infrastructure.¹

Evolving Role of Bispecific Antibodies in RR MM

To begin the discussion, Zahra Mahmoudjafari, PharmD, MBA, BCOP, FHOPA, clinical pharmacy manager at the University of Kansas Health System, outlined the landscape of RR MM care. She noted that despite major strides in treatment, survival rates in the triple-class refractory setting remain poor. Chimeric antigen receptor (CAR) T-cell therapies have improved care, but Mahmoudjafari explained that these therapies are burdened by inherent limitations, including long manufacturing timelines and toxicities.¹

Guidelines suggest that bispecific antibodies, which bind to 2 different cell types to attack myeloma cells more directly, be administered after at least 4 lines of therapy. However, many panelists have begun using these therapies earlier than the fifth line. Brooke Adams, PharmD, BCOP, a clinical pharmacist at Orlando Health, said she is advocating “to get a bispecific earlier than the fifth line.”^1,2

“Whether that’s right or wrong, I personally find it right for the patient,” Adams continued.¹

Grace Elsey, PharmD, clinical pharmacist coordinator at Atrium Health, agreed with the sentiment, explaining that “we’re using [bispecifics] very frequently before the fifth line.” At her practice, third- or fourth-line insurance coverage has not been a concern. “We’ve really pushed them to the forefront, especially in patients that don’t want to do CAR T.”¹

Patient hesitancy toward CAR T-cell therapies and subsequent refusal to initiate them have also motivated many pharmacists to begin bispecifics earlier in the treatment course. Amir Ali, PharmD, BCOP, hematology and oncology therapy clinical pharmacist at USC Norris Comprehensive Cancer Center, said that patients in his practice have begun using artificial intelligence (AI) to better understand the therapy and potential adverse effects. As they note the risks—including neurotoxicities such as CRS or immune effector cell–associated neurotoxicity syndrome (ICANS)—many are discouraged from initiating therapy.^1,3

“When they search for it, they get scared [of] that,” Ali explained. “I’ve actually had 2 patients now [who] reference [AI] and opt out of CAR T for that reason.”¹

A challenge with the broader use of bispecifics includes limited access at many centers. Lizbeth Haker, PharmD, BCOP, pharmacotherapy specialist at Tampa General Hospital, said her practice gets referrals from hundreds of miles away. Haker’s center has been partnering with smaller, rural practices to administer bispecifics and overcome the obstacles many patients face due to distance or financial disadvantages. Laura Sun, PharmD, BCOP, a clinical oncology specialist at Emory Healthcare, echoed these points and emphasized the importance of psychosocial support when offering bispecifics for patients.¹ “I think as long as we can come up with a good social plan…it’s reasonable to offer [bispecifics] to everyone,” she said.¹

Overcoming Operational and Safety Challenges

After eligible patients are identified for bispecific therapies, the focus shifts to logistics and safety. Mahmoudjafari acknowledged the pertinent risks of CRS and neurotoxicity when using bispecifics and said step-up dosing is often used to mitigate initial safety concerns when starting treatment. The panelists expressed varying opinions on the feasibility of initiating step-up treatment in a community clinic vs referring patients to an academic center.¹

For example, Haker noted that many patients have expressed hesitancy and discomfort with completing their step-up doses in community centers. Katherine Tobon, PharmD, BCOP, clinical pharmacy specialist in malignant hematology at Moffitt Cancer Center, agreed, saying that “not all community hospitals…really understand the toxicities to be able to see them and treat them effectively earlier on.” Adams echoed the sentiment, saying some at her institution are “hesitant to send [patients] out in the community space.”¹

Mahmoudjafari shifted the discussion to prophylactic tocilizumab (Actemra; Genentech, Inc) to prevent severe or life-threatening CRS. Prophylactic tocilizumab is effective and induces responses in patients experiencing CRS, but the agent can make patients more susceptible to serious infections such as tuberculosis or bleeding. Liver and gastrointestinal complications are also possible. Mahmoudjafari said she believes that “prophylactic tocilizumab does not come without its own inherent risks.”^1,4,5

“I’ve heard that many community sites would feel a lot more comfortable and sleep better at night if they were giving prophylactic tocilizumab,” Mahmoudjafari said. “It may make you feel better or sleep better at first, but it’s going to wake you up later.”¹

Panelists, including Mikaela McCabe, PharmD, clinical pharmacy specialist at Barnes-Jewish Hospital, pushed back against Mahmoudjafari and argued in favor of prophylactic tocilizumab. McCabe explained that “if we’re admitting somebody for one of these agents, we think they’re probably at higher risk for having some sort of reaction to it,” leading to prophylactic administration.¹

Elsey countered, saying that at Atrium Health, prophylactic tocilizumab use has almost completely ceased. Instead, they utilize steroid-based prophylaxis using dexamethasone in “very small” doses, which Elsey called “pocket dex,” allowing for shared decision-making when it comes time to take another dose. A patient can assess their condition and, if any symptoms have not resolved, take a subsequent dose of dexamethasone. However, Elsey noted that in outpatient settings, tocilizumab is kept on standby, having already been authorized by insurance, in case it becomes necessary.¹

“That way, if you need it, you can pull the trigger and not have to have any concern about it,” Elsey explained.¹

Bridging Academic and Community Care to Deliver Bispecific Therapies

Clear gaps in education remain around bispecific treatments, especially regarding toxicities such as ICANS and CRS, in addition to the risk of infection. Health care providers in community settings or emergency departments may not understand the differences between, for example, sepsis and CRS, including the proper sequencing of treatments and expected adverse effects, according to Adams. If emergency department physicians were more aware of potential adverse effects and ways to mitigate them early on, future complications could be avoided.¹

“I think that’s a huge gap that we’re seeing in the community; every single emergency [department] needs to understand that [adverse effects] are possible,” Adams explained.¹

Following initial administration of bispecifics, it is time to transition the patient back to their home and into the community. Despite many community clinicians’ inexperience with bispecific treatments, Mahmoudjafari spoke to the strong, established relationships between academic centers and community providers, which ensure optimal transitions of care.

Haker noted that they begin planning for a return home “as soon as we get the referral to us,” highlighting the importance of early planning for that transition and prompt coordination with community providers to ensure continued care. Adding to this sentiment, Adams said, “We try to encourage going back to your local provider because, eventually, you’re probably going to need treatments that require closer care.”¹

Ultimately, to safely administer bispecific therapies in the outpatient setting, a center must have “education, triage, and a plan” at a minimum, according to Tobon. Although these are minimum requirements—and more funding and resources would certainly go a long way to perfecting the process—many sites are already trained on many of the processes required to administer in outpatient settings, and just need to “slightly tweak the algorithm” to make it work, according to Ali.¹

“I do think, of course, we can all use more advanced practice providers, more physicians [who] take care of this, but realistically, to mitigate some of the cost with this transition, you have to work with your available resources,” Ali explained. “I think it’s certainly feasible.”¹

REFERENCES

1. Pharmacy Times Clinical Forum at: 67th American Society of Hematology Annual Meeting and Exposition; December 3, 6-9, 2025; Orlando, FL.

2. Bispecific therapies. International Myeloma Foundation. Updated January 12, 2026. Accessed January 14, 2026. https://www.myeloma.org/emerging-therapies/bispecific-therapies

3. CAR T-cell therapy and its side effects. American Cancer Society. Updated July 7, 2025. Accessed January 6, 2026. https://www.cancer.org/cancer/managing-cancer/treatment-types/immunotherapy/car-t-cell.html

4. Le RQ, Li L, Yuan W, et al. FDA approval summary: tocilizumab for treatment of chimeric antigen receptor T-cell-induced severe or life-threatening cytokine release syndrome. Oncologist. 2018;23(8):943-947. doi:10.1634/theoncologist.2018-0028

5. Tocilizumab (intravenous route, subcutaneous route). Mayo Clinic. Updated January 1, 2026. Accessed January 7, 2026. https://www.mayoclinic.org/drugs-supplements/tocilizumab-intravenous-route-subcutaneous-route/description/drg-20073821