Question

How do you decide treatment at first relapse in this patient?

Hint:

At first relapse, it is important to assess previous therapies, performance status, and available treatment options. Monoclonal antibodies and second-line therapies are often used in relapsed patients.

Answer 1

Step 1: Identifying Relapse.
Relapse in multiple myeloma is defined by the reappearance of disease activity after an initial period of remission. Clinical signs of relapse may include worsening of symptoms such as bone pain, anemia, or new organ involvement. Laboratory evidence, such as rising monoclonal protein levels, is used to confirm relapse.

Step 2: Treatment Decision Criteria.
When deciding treatment at first relapse in transplant-ineligible elderly patients, factors to consider include: 1. Previous treatments: If the patient has already received drugs like lenalidomide and bortezomib, switching to other agents or combinations may be necessary.
2. Performance status and comorbidities: Treatment must be chosen based on the patient’s ability to tolerate chemotherapy. For frail patients, lower-intensity regimens may be preferred.
3. Available therapies: Options include second-line therapies such as carfilzomib (proteasome inhibitor) or pomalidomide (IMiD), or monoclonal antibodies like daratumumab in combination with other agents.

Step 3: Tailored Treatment Approach.
The goal is to reintroduce a regimen that the patient has not been exposed to previously while minimizing side effects. For example, if the patient has received lenalidomide and bortezomib in the first line, alternatives like pomalidomide or daratumumab may be considered for second-line treatment.