Regimen | Major toxicities | Adjunctives | Clinical use | Other |
Options for initial relapse | ||||
Daratumumab, lenalidomide, dexamethasone (DRd) | Acute or delayed hypersensitivity reaction, opportunistic infections, diarrhea, fatigue. | Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis. | Preferred for patients relapsing off therapy or while on small doses of single agent lenalidomide or on bortezomib maintenance. | Can interfere with cross-matching and red blood cell antibody screening. |
Daratumumab, bortezomib, dexamethasone (DVd) | Peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, nausea. | Prophylaxis for infusion reactions; antiviral prophylaxis. | Preferred if refractory to full doses of lenalidomide or refractory to a lenalidomide containing triplet. | Can interfere with cross-matching and red blood cell antibody screening. |
Daratumumab, carfilzomib, dexamethasone (DKd) | Hypersensitivity reaction, transient cytopenias, fatigue, diarrhea, hypokalemia, hypertension, dyspnea, serious cardiac dysfunction (approximately 5%). | Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis. | Option for patients refractory to both bortezomib and lenalidomide. | Can interfere with cross-matching and red blood cell antibody screening. |
Isatuximab, carfilzomib, dexamethasone | Hypersensitivity reaction, transient cytopenias, respiratory infections, fatigue, diarrhea, hypertension, serious cardiac dysfunction. | Prophylaxis for infusion reactions; antiviral prophylaxis. | Option for patients refractory to both bortezomib and lenalidomide. | Can interfere with cross-matching and red blood cell antibody screening. |
Bortezomib, lenalidomide, dexamethasone (VRd) | Peripheral neuropathy, transient cytopenias, fatigue, gastrointestinal distress. | Thromboprophylaxis; antiviral prophylaxis. | May be preferred for patients relapsing off therapy or on lenalidomide maintenance. | Subcutaneous, once-weekly dosing of bortezomib decreases toxicity. |
Bortezomib, cyclophosphamide, dexamethasone (VCD) | Peripheral neuropathy, transient cytopenias. | Antiviral prophylaxis; PCP prophylaxis. | May be preferred for patients relapsing while off therapy or on lenalidomide maintenance. | Subcutaneous, once-weekly dosing of bortezomib decreases toxicity. |
Carfilzomib, lenalidomide, dexamethasone (KRd) | Gastrointestinal distress, transient cytopenias, fatigue, hypokalemia, hypertension, dyspnea, serious cardiac dysfunction (approximately 5%). | Thromboprophylaxis; antiviral prophylaxis. | May be preferred for more aggressive relapse in fit patients. | More cumbersome than weekly schedule of bortezomib- or ixazomib-based regimens. |
Carfilzomib, pomalidomide, dexamethasone (off-label) | Transient cytopenias, fatigue, hypokalemia, hypertension, dyspnea, potentially severe diarrhea, serious cardiac dysfunction (approximately 5%). | Thromboprophylaxis; antiviral prophylaxis. | May be preferred for patients with aggressive disease relapsing on standard dose lenalidomide. | |
Bortezomib, pomalidomide, dexamethasone (off-label) | Peripheral neuropathy, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy. | Thromboprophylaxis; antiviral prophylaxis. | May be preferred for patients relapsing on standard dose lenalidomide. | |
Ixazomib, lenalidomide, dexamethasone (IRd) | Diarrhea, constipation, nausea, vomiting, thrombocytopenia, peripheral neuropathy, peripheral edema, and back pain. | Thromboprophylaxis; antiviral prophylaxis. | May be preferred for frail patients or those with a clinically indolent relapse. | Oral regimen. |
Elotuzumab, lenalidomide, dexamethasone | Acute or delayed hypersensitivity reaction, opportunistic infections, hepatic dysfunction, fatigue. | Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis. | May be preferred for frail patients or those with a clinically indolent relapse. | |
Options for multiply relapsed disease: Includes regimens above that have not yet been used | ||||
Daratumumab, pomalidomide, dexamethasone | Hypersensitivity reaction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy. | Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis. | Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor. | Can interfere with cross-matching and red blood cell antibody screening. |
Isatuximab, pomalidomide, dexamethasone | Hypersensitivity reaction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy. | Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis. | Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor. | Can interfere with cross-matching and red blood cell antibody screening. |
Elotuzumab, pomalidomide, dexamethasone | Acute or delayed hypersensitivity reaction, opportunistic infections, hepatic dysfunction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue. | Prophylaxis for infusion reactions; thromboprophylaxis. | Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor. | |
Selinexor, bortezomib, dexamethasone | Thrombocytopenia, neutropenia, and hyponatremia. Neurologic toxicity (eg, dizziness, confusion). | Antiviral prophylaxis; antiemetic prophylaxis. | Reserved for patients with disease refractory to a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody. | Must monitor sodium. |
Selinexor plus dexamethasone | Thrombocytopenia, neutropenia, and hyponatremia. Neurologic toxicity (eg, peripheral neuropathy, dizziness, confusion). | Antiemetic prophylaxis. | Reserved for patients who have had at least four prior regimens, including at least two proteasome inhibitors, at least two immunomodulatory agents, and an anti-CD38 monoclonal antibody. | Oral regimen. Must monitor sodium. |
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