Trajectory of Relapsed/Refractory Multiple Myeloma Treatment Landscape


In their closing thoughts, Mr Haumschild leads the panel in a discussion regarding treatments on the horizon for patients with relapsed/refractory multiple myeloma.

Ryan Haumschild, PharmD, MS, MBA: Pharmacists are positioned to educate patients to monitor for these toxicities and to make sure patients know what to expect as part of their treatment journey. Mr Ali, how do you counsel patients on the risk of developing renal impairment and the overall treatment toxicities? When using a multidrug approach to treatment, which we often do, how do you break down the purpose of each medication and counsel patients on the purpose of that drug and the potential risk of adverse events that could be associated with it?

Amir Ali, PharmD, BCOP: It’s extremely important to educate patients and mention, right off the bat, that renal impairment is very common in multiple myeloma. About 50% of patients will have some level of renal impairment. Unfortunately, that’s associated with reduced overall survival with a lot patients we see. Another point is that in a lot of clinical trials, a lot of these agents and regimens that we’re using don’t uniformly include patients with renal impairment. Often, that’s an exclusion criterion. That’s important to look at.

If you dive into the treatment itself, you start with CD38 agents. If you look at the IKEMA and CANDOR trials, they have different cutoffs for patients with renal impairment. IKEMA had a lower cutoff for eGFR [estimated glomerular filtration rate], so there are a little more data published in that end. If you look at the IMiDs [immunomodulatory imide drugs], those are sometimes associated with kidney dysfunction. Proteasome inhibitors have some nephrotoxicity as well. But besides the treatments themselves, progression of multiple myeloma itself can worsen renal function. It’s 1 of the CRAB [calcium elevation, renal insufficiency, anemia, bone abnormalities] symptoms. We know that those monoclonal free light chains are affecting the kidney. As that starts building up, progression occurs and renal function often declines.

What things can we do, and what can we educate our patients on? First, early treatment to prevent this buildup is key. Additional factors that contribute to renal insufficiency or renal impairment included dehydration. We need to counsel them on managing their hypertension and diabetes. From a pharmacist perspective, those nephrotoxic drugs are often not helping in these situations. It’s important to discuss these points with your patients.

Ryan Haumschild, PharmD, MS, MBA: This has been a great discussion. We have a lot of background on multiple myeloma, the important role that anti-CD38 agents play and how we’re going to continue to extend the lives of these patients for years to come.

There are many exciting things ahead of us within the multiple myeloma landscape, many treatments and algorithms. We’re excited about what the future holds for our patients. Ms Maples, what are the most promising developments on the horizon for patients with relapsed/refractory multiple myeloma, whether it’s screening, therapy, or overall treatment?

Kathryn Tyler Maples, PharmD, BCOP: This is a great question, and it’s 1 that I’m excited about. We have so much to look forward to in the multiple myeloma world. A few things that I’m excited to see are the development of novel targets. We’ve talked a lot about anti-CD38s. We’ve seen a huge growth in the anti-BCMA world, and we’re starting to see other targets, such as GPRC5D and FCRH5. We’re going to start seeing novel targets with new mechanisms in action, which is exciting.

Additionally, there are different types of cellular therapy—allogenic CAR [chimeric antigen receptor] T cells and CAR–NK [natural killer] cells. Hopefully, we can get rid of some of that CRS [cytokine release syndrome]. That’s very exciting in terms of a treatment landscape. In terms of screening and other things that might benefit our patients, we’re starting to learn about soluble BCMA as a possible marker of therapy. The soluble BCMA has a shorter half-life, so that could be a disease marker and give us a faster look at what’s happening. It would be a good option for nonsecretors, who don’t secret those proteins into the blood and urine. We have a lot of exciting things from the treatment side and from the screening side. We’ve already talked about MRD [minimal residual disease] negativity, and I’m hopeful that we’re moving closer to a cure for these patients.

Ryan Haumschild, PharmD, MS, MBA: Thank you to my expert panel for such a robust discussion around relapsed/refractory multiple myeloma. I learned a lot. I ‘m sure our viewers did as well. To our viewing audience, we hope you found this Pharmacy Times® Peer Exchange to be rich and informative.

Transcript edited for clarity.

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