I am in my initial treatment phase and my dosing is Revlimid days 1-21 at 25mg, Velcade days 1,4,8,11,22 ,25, and dex 20mg once a week.
Most people seem to be on 40mg of dex. My local specialist says it is fine as did the myeloma specialists at City of Hope and SCCA, but I am wondering if the research indicates a higher does of dex is better.
Thanks for your feedback
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CindyBrown - Name: Cindy Brown
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: 4/26/14
- Age at diagnosis: 48
Re: Dex dose during RVD / VRD?
Hi Cindy,
My induction was 25 mg Revlimid x 21 and 20 mg Dexamethasone weekly. I refused Velcade . I did just fine for the first 3 months and then the Revlimid needed to be reduced to 15 mg, dex stayed the same.
I also didn't want a stem-cell transplant and am doing just fine. My initial IgG was around 7400 and now is in the normal range. It took about 13 months.
Kate
My induction was 25 mg Revlimid x 21 and 20 mg Dexamethasone weekly. I refused Velcade . I did just fine for the first 3 months and then the Revlimid needed to be reduced to 15 mg, dex stayed the same.
I also didn't want a stem-cell transplant and am doing just fine. My initial IgG was around 7400 and now is in the normal range. It took about 13 months.
Kate
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Kate - Name: Kate
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: Dec. 2012
Re: Dex dose during RVD / VRD?
This question has been asked before. Others can correct me but I do not think there has ever been a clinical trial or study comparing the effectiveness of different dosages of dex.
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goldmine848 - Name: Andrew
- When were you/they diagnosed?: June 2013
- Age at diagnosis: 60
Re: Dex dose during RVD / VRD?
We're not aware of any trials that have compared different doses of dex when combined with both Revlimid AND Velcade.
However, there has been a study that compared Revlimid plus 40 mg dex on days 1-4, 9-12, and 17-20 of a 28-day cycle ("high-dose dex") versus Revlimid plus 40 mg dex on days 1, 8, 15, and 22 of a 28-day cycle ("low-dose dex").
The study found superior overall survival in the low-dose dex group, despite the fact the share of patients who achieved a partial response or better to treatment was higher in the high-dose dex group.
These results led to greater use of the lower-dose dex regimen when dex is combined with Revlimid. In addition, myeloma specialists now are more inclined to use lower dex doses in other regimens than was the case before the trial.
It's also worth noting that the trial's results highlight that higher response rates do not always lead to better overall survival outcomes.
You can read about the study in this Beacon news article:
"Study Shows Higher Survival With Revlimid And Low-Dose Dexamethasone Than Revlimid And High-Dose Dexamethasone In Multiple Myeloma Patients," Myeloma Beacon, October 27, 2009.
The article includes a link to the abstract for the study. We don't believe the full text of the final draft of the article is available online free of charge. However, the author manuscript is, and can be viewed in full here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042271/
However, there has been a study that compared Revlimid plus 40 mg dex on days 1-4, 9-12, and 17-20 of a 28-day cycle ("high-dose dex") versus Revlimid plus 40 mg dex on days 1, 8, 15, and 22 of a 28-day cycle ("low-dose dex").
The study found superior overall survival in the low-dose dex group, despite the fact the share of patients who achieved a partial response or better to treatment was higher in the high-dose dex group.
These results led to greater use of the lower-dose dex regimen when dex is combined with Revlimid. In addition, myeloma specialists now are more inclined to use lower dex doses in other regimens than was the case before the trial.
It's also worth noting that the trial's results highlight that higher response rates do not always lead to better overall survival outcomes.
You can read about the study in this Beacon news article:
"Study Shows Higher Survival With Revlimid And Low-Dose Dexamethasone Than Revlimid And High-Dose Dexamethasone In Multiple Myeloma Patients," Myeloma Beacon, October 27, 2009.
The article includes a link to the abstract for the study. We don't believe the full text of the final draft of the article is available online free of charge. However, the author manuscript is, and can be viewed in full here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042271/
Re: Dex dose during RVD / VRD?
My induction therapy was 15 mg Revlimid 21 days on / 7 days off, and dex 40 mg once per week. This regimen brought my numbers down very quickly to a stable level. But, I had a lot of problems with the 40 mg of dex.
When I relapsed and restarted treatment, I again was taking 15 mg of Revlimid, but my doctor lowered my dex to 20 mg once per week. Again my numbers dropped quickly to a stable level where they've been for 19 months.
My Revlimid dose was recently lowered to 10 mg since I developed a decrease in my blood counts recently. A 4 week break from Revlimid and my counts recovered. One month on the 10 mg level of Revlimid and 20 mg of dex has kept my m-spike and FLC stable.
So, in my case, 20 mg of dex works just fine and I have minimal side effects from it. The 40 mg was really hard for me to tolerate.
Nancy in Phila
When I relapsed and restarted treatment, I again was taking 15 mg of Revlimid, but my doctor lowered my dex to 20 mg once per week. Again my numbers dropped quickly to a stable level where they've been for 19 months.
My Revlimid dose was recently lowered to 10 mg since I developed a decrease in my blood counts recently. A 4 week break from Revlimid and my counts recovered. One month on the 10 mg level of Revlimid and 20 mg of dex has kept my m-spike and FLC stable.
So, in my case, 20 mg of dex works just fine and I have minimal side effects from it. The 40 mg was really hard for me to tolerate.
Nancy in Phila
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NStewart - Name: Nancy Stewart
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 3/08
- Age at diagnosis: 60
Re: Dex dose during RVD / VRD?
Dosing of Dex with VRD/RVD. Well, there has not been a study to combine different dosing of dex within the context of Velcade and Revlimid. As you can see by the posts, there are different dex styles / treatments.
The trial that has done the most to change how we use dex, ECOG4A03, compared Revlimid / dex (high dose) vs Revlimid / dex (low dose).
High-dose dex: 40 mg, days 1-4, 9-12, 17-20 (total 480 mg).
Low-dose dex: 40 mg, days 1, 8, 15, 22 (total 160 mg).
(You all can argue the "low dose" may not be that low.) We learned from the ECOG4A03 study (Rajkumar Lancet Oncology 2010) that more dex is not necessarily better for survival end points. High dose dex was associated with increased toxicities and increased early fatalities with equivalent survival by 3 years. As such, low-dose dex dosing is the standard of care for Revlimid / dex.
In the initial phase 1/2 study of RVD in newly diagnosed patients lead by Dr. Richardson, the protocol was amended to 20 mg of dex days 1,2, 4, 5, 8, 9,11&12 for cycles 1-4 (160 mg a cycle) and 10 mg on the same days cycles 5 through 8 (80 mg a cycle) from 40 mg (Richardson Blood 2010).
Generally, I dose dex as was done in the Richardson RVD trial, with the caveat that I drop to 20 mg on the days of Velcade (bortezomib) after 4 cycles to make it easier for patients to remember (and it is 4 less dex days).
However, you will find 40 mg weekly (days 1, 8, 15) is used frequently, but is less dex per cycle (120 mg a cycle).
*Importantly, like all medications given, dose adjustments are put into the context of disease control and toxicities. Dex, as most of you can attest to, can have some very obvious and significant side effects, so dosing should be altered based on the these needs.
The trial that has done the most to change how we use dex, ECOG4A03, compared Revlimid / dex (high dose) vs Revlimid / dex (low dose).
High-dose dex: 40 mg, days 1-4, 9-12, 17-20 (total 480 mg).
Low-dose dex: 40 mg, days 1, 8, 15, 22 (total 160 mg).
(You all can argue the "low dose" may not be that low.) We learned from the ECOG4A03 study (Rajkumar Lancet Oncology 2010) that more dex is not necessarily better for survival end points. High dose dex was associated with increased toxicities and increased early fatalities with equivalent survival by 3 years. As such, low-dose dex dosing is the standard of care for Revlimid / dex.
In the initial phase 1/2 study of RVD in newly diagnosed patients lead by Dr. Richardson, the protocol was amended to 20 mg of dex days 1,2, 4, 5, 8, 9,11&12 for cycles 1-4 (160 mg a cycle) and 10 mg on the same days cycles 5 through 8 (80 mg a cycle) from 40 mg (Richardson Blood 2010).
Generally, I dose dex as was done in the Richardson RVD trial, with the caveat that I drop to 20 mg on the days of Velcade (bortezomib) after 4 cycles to make it easier for patients to remember (and it is 4 less dex days).
However, you will find 40 mg weekly (days 1, 8, 15) is used frequently, but is less dex per cycle (120 mg a cycle).
*Importantly, like all medications given, dose adjustments are put into the context of disease control and toxicities. Dex, as most of you can attest to, can have some very obvious and significant side effects, so dosing should be altered based on the these needs.
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Dr. Ken Shain - Name: Ken Shain, M.D., Ph.D.
Beacon Medical Advisor
Re: Dex dose during RVD / VRD?
Husband is currently undergoing induction therapy:
Velcade days 1,4,8,11 then ten days off.
Dex 20 mg on the day of, and the day after, each Velcade injection
Revlimid days 1-14 with seven days off
Husband is currently done with his first week of the third round of treatment with plans to do a stem cell harvest after he has completed his fourth round of treatment, if his numbers are good.
Velcade days 1,4,8,11 then ten days off.
Dex 20 mg on the day of, and the day after, each Velcade injection
Revlimid days 1-14 with seven days off
Husband is currently done with his first week of the third round of treatment with plans to do a stem cell harvest after he has completed his fourth round of treatment, if his numbers are good.
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Melanie - Name: Melanie
- Who do you know with myeloma?: husband
- When were you/they diagnosed?: July 2014
- Age at diagnosis: 54
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