MULTIPLE MYELOMA TREATMENT REGIMENS

The selection, dosing, and administration of anticancer agents and the management of associated toxicities are complex. Drug dose
modifications and schedule and initiation of supportive care interventions are often necessary because of expected toxicities and
because of individual patient variability, prior treatment, and comorbidities. Thus, the optimal delivery of anticancer agents requires a
healthcare delivery team experienced in the use of such agents and the management of associated toxicities in patients with cancer.
The cancer treatment regimens below may include both FDA-approved and unapproved uses/regimens and are provided as references
only to the latest treatment strategies. Clinicians must choose and verify treatment options based on the individual patient.
NOTE: GREY SHADED BOXES CONTAIN UPDATED REGIMENS.

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
REGIMEN DOSING
Primary Therapy for Transplant Candidates
Bortezomib (Velcade) + Days 1, 4, 8, 11: Bortezomib 1.3mg/m2.
dexamethasone1–3 Days 1–4 (all cycles) and Days 9–12 (cycles 1 and 2): Dexamethasone
40mg orally.
Repeat cycle every 3 weeks for 4 cycles.
Bortezomib + doxorubicin Days 1, 4, 8, 11: Bortezomib 1.3mg/m2.
(Adriamycin) + Days 1–4: Doxorubicin 9mg/m2.
dexamethasone1,4 Days 1–4, 9–12, 17–20: Dexamethasone 40mg orally.
Repeat cycle every 3 weeks for 3 cycles.
Bortezomib + thalidomide Days 1, 4, 8, 11: Bortezomib 1.3mg/m2.
(Thalomid) + dexamethasone 1,5 Days 1, 2, 4, 5, 8, 9, 11, 12: Dexamethasone 40mg orally.
Days 1–14: Thalidomide 100mg orally then escalate 200mg thereafter.
Repeat cycle every 3 weeks for 3 cycles.
Lenalidomide (Revlimid) + Days 1–21: Lenalidomide 25mg orally once daily, plus
dexamethasone 1,6 Days 1, 8, 15 and 22: Dexamethasone 40mg/day orally.
Repeat cycle every 4 weeks for 4 cycles or until disease progression.
Primary Therapy for Non-Transplant Candidates
Lenalidomide + Days 1–21: Lenalidomide 25mg orally once daily, plus
dexamethasone 1,6 Days 1, 8, 15 and 22: Dexamethasone 40mg/day orally.
Repeat cycle every 4 weeks for 4 cycles or until disease progression.
MPB (melphalan [Alkeran] + Days 1–4: Melphalan 9mg/m2 orally.
prednisone + bortezomib)1,7,8 Days 1–4: Prednisone 60mg/m2 orally.
Cycles 1–4
Days 1, 4, 8, 11, 22, 25, 29, 32: Bortezomib 1.3mg/m2.
Cycles 5–9
Days 1, 8, 22, 29: Bortezomib 1.3mg/m2.
Repeat cycle every 6 weeks for up to 9 cycles.
Melphalan + prednisone + Days 1–7: Melphalan 4mg/m2.
thalidomide1,9 Days 1–7: Prednisone 40mg/m2 orally.
Repeat cycle every 6 weeks for 12 cycles, plus
Days 1–7: Thalidomide 100mg/day orally.
Repeat every 4 weeks.
Melphalan + prednisone + Days 1–4: Melphalan 0.18mg/kg.
lenalidomide1,10,11 Days 1–4: Prednisone 2mg/kg orally.
Days 1–21: Lenalidomide 10mg.
Repeat every 4 weeks for 9 cycles (followed by maintenance lenalidomide
10mg/day).
References
1. NCCN Clinical Practice Guidelines in Oncology™. Multiple versus lenalidomide plus low-dose dexamethasone as initial
Myeloma. v 1.2012. Available at: http://www.nccn.org/professio therapy for newly diagnosed multiple myeloma: an open-label
nals/physician_gls/pdf/myeloma.pdf. Accessed March 9, 2012. randomised controlled trial. Lancet Oncol. 2010;11:29–37.
2. Avet-Loiseau H, Leleu X, Roussel M, et al. Bortezomib plus 7. San Miguel JF, Schlag R, Khuageva NK, et al. Bortezomib plus
dexamethasone induction improves outcome of patients with melphalan and prednisone for initial treatment of multiple
t(4;14) myeloma but not outcome of patients with del(17p). myeloma. N Engl J Med. 2008;359:906–917.
J Clin Oncol. 2010;28:4630–4634. 8. Mateos MV, Richardson PG, Schlag R, et al. Bortezomib plus
3. Harousseau JL, Attal M, Avet-Loiseau H, et al. Bortezomib plus melphalan and prednisone compared with melphalan and
dexamethasone is superior to vincristine plus doxorubicin plus prednisone in previously untreated multiple myeloma: updated
dexamethasone as induction treatment prior to autologous follow-up and impact of subsequent therapy in the phase III
stem cell transplantation in newly diagnosed multiple myeloma: VISTA trial. J Clin Oncol. 2010;28:2259–2266.
results of the IFM 2005-01 phase III trial. J Clin Oncol. 2010; 9. Mateos MV, Oriol A, Martínez-López J, et al. Bortezomib,
28:4621–4629. melphalan, and prednisone versus bortezomib, thalidomide,
4. Sonneveld P, Schmidt-Wolf I, van der Holt B, et al. HOVON-65/ and prednisone as induction therapy followed by maintenance
GMMG-HD4 randomized phase III trial comparing bortezomib, treatment with bortezomib and thalidomide versus bortezomib
doxorubicin, dexamethasone (PAD) Vs VAD followed by high- and prednisone in elderly patients with untreated multiple
dose melphalan (HDM) and maintenance bortezomib or thali- myeloma: a randomised trial. Lancet Oncol. 2010;11:934–941.
domide in patients with newly diagnosed multiple myeloma 10. Palumbo A, Dimopoulos MA, Delforge M, et al. A phase III
[abstract]. Blood. 2010;116:Abstract 40. study to determine the efficacy and safety of lenalidomide in
5. Cavo M, Tacchetti P, Patriarca F, et al; GIMEMA Italian Myeloma combination with melphalan and prednisone (MPR) in elderly
Network. Bortezomib with thalidomide plus dexamethasone patients with newly diagnosed multiple myeloma [abstract].
compared with thalidomide plus dexamethasone as induction Blood. 2009;114:Abstract 613.
therapy before, and consolidation therapy after, double auto- 11. Palumbo A, Delforge M, Catalano J, et al. A phase III study
logous stem-cell transplantation in newly diagnosed multiple evaluating the efficacy and safety of lenalidomide combined
myeloma: a randomised phase 3 study. Lancet. 2010;376: with melphalan and prednisone in patients ≥65 years with
2075–2085. newly diagnosed multiple myeloma: continuous use of lenali-
6. Rajkumar SV, Jacobus S, Callander NS, et al; Eastern Cooperative domide vs fixed-duration regimens [abstract]. Blood. 2010;
Oncology Group. Lenalidomide plus high-dose dexamethasone 116:Abstract 622.
(Revised 03/2012)
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