- What maintenance therapy options exist for patients that are unable to tolerate Revlimid?
If tolerability to Revlimid is an issue, the doctor may first want to try lowering the dose of Revlimid or try providing supportive care measures if the patient is experiencing issues such as rash or diarrhea. If the patient needs to be switched to another maintenance therapy, currently, Ninlaro (ixazomib)—an oral agent in the same drug class as Velcade (bortezomib) and Kyprolis (carfilzomib)—is a possible option for maintenance therapy. Ninlaro has been tested as maintenance therapy in a phase 3 clinical trial in newly diagnosed patients who had received a stem cell transplant. The trial compared maintenance with Ninlaro to no maintenance following stem cell transplant and showed that more patients lived longer without disease progression on Ninlaro maintenance therapy compared to those who received no maintenance therapy. If Ninlaro is unavailable to patients, Velcade may be another option.
Another option such as Pomalyst (pomalidomide)—an oral agent in the same drug class as Revlimid—is typically given to patients who have progressed on Revlimid; meaning that they no longer respond to Revlimid treatment. The use of the monoclonal antibody Darzalex (daratumumab) as maintenance therapy is only limited to patients on clinical trials. Ultimately, Darzalex shows promise when used in newly diagnosed patients and existing clinical trial data supports its use as maintenance therapy, but before it can be widely used, questions still remain regarding its side effect profile and the implications of prolonged use of an immunotherapy.
- After stem cell transplant, when does Revlimid maintenance therapy begin and at what dose?
For patients with standard-risk myeloma, maintenance therapy with Revlimid begins at day 100 post-transplant. This timing is optimal to introduce a new treatment since patients’ blood cell counts have recovered and they are about 80% to 90% back to normal. For patients with high-risk myeloma (those at highest risk for relapse), maintenance therapy begins day 60 post-transplant. The reason is that maintaining disease control is the highest priority for these patients.
The typical dose of Revlimid maintenance is 10 mg per day for 21 days. The dose should only be reduced due to intolerance issues.