Treating Multiple Myeloma in the Second Line: Which Option Should You Choose?

An explosion of therapeutic choices makes the decision challenging

• After first-line treatment with lenalidomide, bortezomib, and dexamethasone (RVD) or carfilzomib, lenalidomide, dexamethasone (KRD), which option do you choose for the second line?
• Some patients have a prolonged benefit from the elotuzumab-pomalidomide-dexamethasone regimen.
• After progressing on an anti-CD38 antibody, the likelihood of getting a response with another one is very low.

The number of novel multiple myeloma treatments has grown exponentially over the last couple of decades, from just two FDA-approved therapies 15 years ago, to more than a dozen today. With so many options comes a difficult choice. After treatment with lenalidomide, bortezomib, and dexamethasone (RVD) or carfilzomib, lenalidomide, dexamethasone (KRD) in the first line, where should you turn for second-line therapy?

For patients with biochemical progression, Dr. Ravi Vij, professor of medicine at Washington University School of Medicine in St. Louis, often chooses elotuzumab, pomalidomide, and dexamethasone. “Some patients can have fairly prolonged benefit from that regimen,” he said during a virtual SurvivorNet Connect forum from the 2021 ASCO Annual Meeting.

Dr. Thomas Martin, a hematologist-oncologist at UCSF Medical Center, doesn’t often use elotuzumab. “If it’s somebody that I really want to get a response in, I’m going to give them a CD38-based regimen,” he says.

Once a patient has progressed through the first anti-CD38 antibody, should you try another one?

“Don’t do it,” advises Dr. Saad Usmani, director of clinical research at Levine Cancer Institute in Charlotte, North Carolina. “If you’ve progressed on one anti-CD38, the likelihood of getting a response with the other is very low.”

Dr. Martin also doesn’t recommend switching out a drug in a patient who is progressing. “If you’re getting daratumumab and pomalidomide and you’re progressing, I wouldn’t switch the partner,” he says. “I think you can use it again, but you need to give at least maybe a three- to six- month break between administration of that CD38-based agent.”