/ Updated February 9th, 2022

What Are The Treatment Options for Patients on First Relapse?

Creator: James Roland
Published: 2022-01-12T16:04:03-05:00

: Dr. Joshua Richter Written by: James Roland

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The First Relapse

The first relapse of multiple myeloma is usually treated with a different combination of medications than what was used in induction and maintenance therapies.
A relapse may be an indication that the cancer has grown resistant to a particular medication.
It's important to work with your doctor to find a treatment regimen that is both effective and keeps side effects to a minimum.

After your initial treatment for multiple myeloma, you may experience a period of remission, with few disease symptoms and a restored quality of life. But most people with multiple myeloma can expect a relapse at some point, which will mean a new round of treatmentsoften with one or more different medications than were used in your induction therapy or as part of your maintenance therapy during remission.

But most patients have some options when it comes to treatment for that first relapse, says Matthew Pianko, MD, hematologist with the Rogel Cancer Center at the University of Michigan in Ann Arbor. "When deciding about which type of regimen we would choose for a patient with a first relapse, we would look first at what type of treatment they had received in the past and what their maintenance therapy had been," he says. "In general, most patients have been on maintenance therapy with lenalidomide (Revlimid)."

Medication Considerations

Dr. Pianko explains that a relapse could indicate that the disease has become resistant to lenalidomide. And like most initial therapies that include three types of medications, treating someone experienced a first relapse will also usually require three drugs, at least two of which should be new to the patient.

"Several common options can include a drug called daratumumab (Darzalex), which is a monoclonal antibody drug that can be given either intravenously or under the skin in combination with other myeloma drugs," Dr. Pianko says. "This is a common choice at first relapse. It can be paired with another oral type of drug called pomalidomide (Pomalyst), which is like a next generation version of Revlimid."

Pomalidomide is a pill that is taken daily for three weeks in a row, with one week off. It often has side effects that can be similar to lenalidomide. Among them are body aches, difficult or painful urination, tarry stools, and congestion.

"Dexamethasone, a corticosteroid, is the third drug that is often included as part of therapy for relapsed multiple myeloma at first relapse," Dr. Pianko says. "Generally, many of our regimens are paired with dexamethasone. It’s a drug that seems to make all of our other myeloma drugs work better."

There are side effects that can be an issue with dexamethasone, including nausea and stomach irritation, dizziness, and insomnia. Dr. Pianko notes that side effects are often dose dependent and that adjusting the dose may be appropriate, especially when considering a patient’s age or their prior treatment history.

Another option for multiple myeloma patients in first relapse is a selective proteasome inhibitor called carfilzomib (Kyprolis). It's an intravenous drug in the same family as the widely used myeloma medication bortezomib (Velcade). "Carfilzomib can be an effective option for patients with relapsed myeloma," Dr. Pianko says. "It can be paired with many other types of myeloma drugs, particularly daratumumab or pomalidomide. In general, a patient's regimen that’s chosen at first relapse can take into account their prior treatment history."

Dr. Pianko adds that there have been significant advances in multiple myeloma drugs in recent years, but there has yet to be many direct comparisons to determine which medications or combination of medications produce the best outcomes. "Work with your doctor to try to find the best fit for you based on your other medical conditions and your prior treatment history," he says.

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James Roland has been a health journalist since 2007, not long after his father died of non-Hodgkin's lymphoma. Read More