Selection of multiple myeloma therapy at first relapse

There is no single standard therapy for relapsed or refractory MM, and practice varies widely; as such, we encourage eligible patients to participate in clinical trials. This algorithm illustrates our preferred and alternative regimens for next systemic therapy in most patients with first relapse. Other regimens are available and may be used by other experts. The choice for an individual must take into account expected toxicities, comorbidities, drug accessibility, and disease aggressiveness.

CAR: chimeric antigen receptor; DKd: daratumumab, carfilzomib, and dexamethasone; DPd: daratumumab, pomalidomide, and dexamethasone; DRd: daratumumab, lenalidomide, and dexamethasone; DVd: daratumumab, bortezomib, and dexamethasone; ERd: elotuzumab, lenalidomide, and dexamethasone; HCT: hematopoietic cell transplantation; IRd: ixazomib, lenalidomide, and dexamethasone; IsaKd: isatuximab, carfilzomib, and dexamethasone; IsaPd: isatuximab, pomalidomide, and dexamethasone; KPd: carfilzomib, pomalidomide, and dexamethasone; KRd: carfilzomib, lenalidomide, and dexamethasone; MM: multiple myeloma; SVd: selinexor, bortezomib, and dexamethasone; VCd: bortezomib, cyclophosphamide, and dexamethasone; VPd: bortezomib, pomalidomide, and dexamethasone.

* The roles of these modalities are rapidly evolving, and referral to a center with expertise allows for an informed and individualized approach.

¶ We use the following cutoffs to define refractory and not-refractory MM to guide therapy:

Refractory: Progression within 60 days of exposure to an agent at standard doses.
Sensitive: Progression >60 days from last exposure or progression on minimal therapy (eg, lenalidomide 10 mg or monthly daratumumab).

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Selection of multiple myeloma therapy at first relapse

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