There are new guidelines issued by NCCN that make recommendations on how to treat multiple myeloma.
However, the new update mentions that the NCCN panel was awaiting publication of two Phase III studies prior to designating the combination of lenalidomide/dexamethasone as a category 1 recommendation, so perhaps yet another update will be forthcoming. "Of course, it is important to note that lenalidomide/dexamethasone displayed better outcomes compared to dexamethasone alone regardless of prior thalidomide exposure," Herrington added.
Other new additions to the guide include a category 2b recommendation for a bortezomib/thalidomide/dexamethasone combination for primary induction therapy for transplant as well as a dexamethasone/cyclophosphamide/etoposide/cisplatin (DCEP) regimen as an option for salvage therapy.
According to Herrington, patients with a history of venous thromboembolism may be less susceptible to recurrence when treated with a bortezomib/pegylated liposomal doxorubicin combination than with thalidomide and its analogs. Also, if patients are susceptible to dexamethasone-induced adverse effects such as hyperglycemia, the use of a non-steroid regimen like bortezomib, with or without the doxorubicin, may be beneficial.
Another interesting question is which bisphosphonate to use to prevent fractures in MM patients, Herrington said. "Based on results from Zervais et al., the use of zoledronic acid (Zometa, Novartis) produces a 9.5-fold increased risk of osteonecrosis of the jaw compared with pamidronate," he pointed out. "Many physicians are now using pamidronate for skeletal fracture prophylaxis instead of zoledronic acid." However, in the new NCCN guide, both agents have been added as options for adjunctive treatment of bone disease.
The new NCCN multiple myeloma guide can be accessed at http://www.nccn.org/.