Frontline or First Line Treatments for Non-Transplant Eligible and Transplant Eligible.  

This week's Ask Dr. Durie comes from a recently diagnosed patient who wants to know what are my best initial or frontline therapy options? and obviously a very key, important question. This particular gentleman is in his seventies and so most likely is not a candidate or interested in pursuing an autologous stem cell transplant (ASCT). And so in his case, the recommended regimen is a very excellent recommendation of the combination of Daratumumab, REVLIMID, and dexamethasone, a three-drug triplet regimen called the MAIA regimen, which has produced excellent results with average remissions which exceed four years. 

And so that's really an excellent regimen, is what is called the standard of care for non-transplant patients in the front-line setting for patients who are considering autologous stem cell transplantation. The my regimen can also be used, but typically we use the Velcade, REVLIMID, and dexamethasone regimen as a first choice to achieve that first remission, with the idea to consider the use of autologous stem cell transplant. 

So the choices are clear and the benefits are really good. There are a number of backup regimens that can be considered, for example, instead of REVLIMID, one can use thalidomide or bortezomib instead of Velcade. One can consider Kyprolis, which is carfilzomib, especially in the high-risk setting. There are a number of options. If a patient is more frail, one can use a doublet of Velcade and dexamethasone, particularly if there are kidney problems or just simply REVLIMID and dex and an all-oral regimen, which works well for an older patient. 

The answer to this particular patient is that the options are rather clear. The only new thing to consider is the possibility to use four drugs or quadruplets rather than a triplet, and adding daratumumab, an anti-CD38 monoclonal antibody, or isatuximab, another one, to give a four-drug regimen such as Dara+VRD or Isa+VRD. 

These are options and we just need more data to indicate if this would really become a new standard of care moving forward. So bottom line, options are pretty clear either daratumumab/Rev/dex, the MAIA regimen, or possibly Velcade, REVLIMID, and dexamethasone, particularly if any high-risk features have been noted on bone marrow FISH testing.