In this video series, we've been exploring bispecific antibodies in multiple myeloma. These are off the shelf drugs that attach to the myeloma cell, along with a local immune cell at the same time to engage that immune cell to kill myeloma. It is an advanced form of immunotherapy and is having a prolific impact on our approach to treating myeloma. In the last video, we reviewed the early side effects of cytokine release syndrome or CRS and immune effector cell-associated neurotoxicity syndrome or ICANS. In this video, I will review the later side effects that can occur. Namely infections, low white blood cell counts and low immunoglobulin levels, also known as hypogammaglobulinemia. Although bispecific antibodies are designed to hook onto myeloma cells and engage immune cells to destroy those myeloma cells, there is inevitably some friendly fire. This means that patient's normal plasma cells can be depleted, resulting in less immunoglobulin production.
Furthermore, white blood cell production and maturation can be impaired. And thirdly, T-cells do play a key role in immunity and as they are engaged to destroy myeloma cells, regular T-cell function may also be dampened. All of these effects put patients at considerable risk of infection, whereas with CAR T-cell therapy, only one infusion is given. With bispecific antibodies, patients generally undergo ongoing therapy as often as weekly. For this reason, side effects with bispecific antibodies may be prolonged. Well, what can we do to prevent infections? We take this threat very seriously, and like many other myeloma therapies, patients will be given preventative treatments to reduce the risk of infection. Practices will vary among institutions, but most will be given the following or a similar protocol to this. Number one, PJP prophylaxis with atovaquone or another agent. PJP or pneumocystis jiroveci pneumonia can be a severe infection in myeloma patients on bispecifics. We can reduce that risk of it with a preventative drug.
Number two, an antiviral drug. There are risks for several viral infections, including shingles while on bispecifics. Therefore, an antiviral therapy is generally given. Number three, IVIG if the IgG level is low. When a patient has hypogammaglobulinemia or a low IgG level, typically less than 400 or 500, they are at higher risk of severe infection. We can replace that with IVIG or intravenous immunoglobulin. Number four, white blood cell growth factors for low white blood cell counts. If patients become neutropenic, which means their neutrophil type of white blood cell count is very low, we may give them growth factors to increase the production of those white cells. Number five, vaccinations. We may provide additional vaccinations for patients, especially for COVID, influenza and pneumococcus. Number six, antibiotics. Although we do not generally give these to all patients, certain patients are at higher risk. Those patients may be given prophylactic or preventative antibiotics.
Number seven, antifungals. We do not routinely provide these as prophylaxis, but some patients may be given this treatment, especially if their blood counts are low. So what should patients and their care partners be watching for? Well, infections can manifest in multiple ways, especially with fever, unexpected fatigue and confusion. But literally, any other symptom consistent with an infection should be watched for. This communication with a patient's healthcare team is critical to catching infections earlier. Bispecific antibodies are no doubt going to be increasingly used in myeloma because they're highly effective and generally easy to administer. However, it is critical to remember that safety is paramount when using these agents, especially since they may adversely affect the immune system. We must take all precautions in prevention as well as early detection of infections to ensure they do not become severe.
