What does it mean to be refractory to Revlimid?
In this week's video, Dr. Durie discusses how to tell if you are refractory to the drug Revlimid® and what other combination therapies could be available as an alternative.
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IMF Chairman Brian G.M. Durie, MD welcomes your questions about the latest myeloma treatments, research, controversies, and quality of life issues. If you have a question you think might be of interest to the myeloma community, please send to [email protected]!
This week’s “Ask Dr. Durie” comes from a gentleman who wants to know: “What does it mean if you are lenalidomide or Revlimid® refractory? And if so, what would be treatment options?” So, this is a great question, a very common question. It’s important to know whether Revlimid® could still work or whether you need to switch to something else.
And so, the major definition for being refractory to lenalidomide, Revlimid, is that you must have progressed on full doses of Revlimid or had an inadequate response with full doses, or the maximum doses that could be tolerated for the Revlimid.
And so, on the opposite side, Revlimid could still be used, you are not refractory if you progress just with low doses typically used for long term maintenance, or if you took Revlimid in the past but then have relapsed off of treatment, so you’ve been on no maintenance for example.
And so, this is very, very important in terms of, what are the treatment options? And so, I think it’s excellent to try to summarize, Okay, if you are not refractory, if it’s still possible to use the Revlimid, what would be the treatment options? Well, combining Revlimid with any one of several new agents would definitely be feasible. Daratumumab would be a strong option, but also Kyprolis® can be used, ixazomib can be used, elotuzumab, all in combination with Revlimid, and we have excellent results with all of those agents.
I might mention in passing that before switching to one of those things, what the doctor might suggest would be perhaps to just increase the dose of the Revlimid first or perhaps add in some weekly dexamethasone to see if this minor tweaking might be sufficient before switching to a completely new or additional triplet regimen.
So, for patients who are clearly refractory to Revlimid, the main option is to use a combination which includes pomalidomide. And so, in this case, again, there are very clear options where one can use daratumumab, pomalidomide, and dex. One can use any one of several of our newer agents combined with pomalidomide and dex. Such as ixazomib, elotuzumab, one can use the new monoclonal antibody isatuximab. One can use several of those types of combinations, even an older combination such as Velcade®, Cytoxan®, and dex can be considered in this setting.
And so, BOTTOM Line, in this case, is that it is very important to establish if you are refractory or not, and the, to discuss carefully with your doctor what might be the best option for you depending on what has happened with prior therapies.
Dr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.