What are the benefits and/or drawbacks of using a drug used during induction therapy also for maintenance?
We are on CyBorD (VCD) at the moment. Over the course of the last few months, we have had discussions of using Revlimid as maintenance, and more recently using Velcade as maintenance.
Since Revlimid and Velcade work in different fashions, is it more beneficial to use Velcade until it potentially stops working, then switch to Revlimid? Or is it better to switch to Revlimid and go back to Velcade if necessary for another induction.
Is it better to use the induction drug for maintenance, or another drug for maintenance?
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Re: Using a drug from induction therapy for maintenance?
You bring up an excellent point. The role of maintenance therapy in myeloma is still being explored, particularly with different induction regimens. Whether the optimal strategy is to use all drugs together upfront, or sequentially, also remains unclear.
While one could potentially use the same drug that was used in the induction regimen, particularly if the response to the induction regimen is good (for example, many patients in the CALGB trial of lenalidomide (Revlimid) maintenance had received Revlimid induction as well), maintenance therapy with a drug that is completely different from the original induction regimen allows a patient's myeloma cells to be exposed to new drug with a completely different mechanism of action.
Moreover, the risk of cumulative toxicity (such a neuropathy with bortezomib (Velcade), or risk of second cancers with cyclophosphamide or Revlimid) should be taken into account when considering the use of the same drug both during induction and maintenance phase.
Having said that, there are certain points to keep in mind before considering the type and duration of maintenance therapy.
Maintenance therapy in myeloma is given with the aim of prolonging overall survival and maintaining a person in remission for as long as possible, without causing significant side effects and compromising the quality of life..
Genetic features play an important role in determining the kind of therapy that should be used for maintenance. At Mayo Clinic, our approach for the 'standard-risk' patients, outside of clinical trials, is to give 2 cycles of consolidation with Revlimid post transplant to deepen the response, followed by maintenance therapy with Revlimid if a patient is Revlimid-responsive and not in at least a very good partial remission (VGPR). All such therapies are commenced post transplant only after discussing the pros and cons.
We do use Velcade as maintenance therapy (with or without Revlimid) if certain cytogenetic features [chromosomal abnormalities] are present. Long term consequences should also be discussed with the patients prior to embarking on maintenance.
While we do use combinations of Velcade and Revlimid as maintenance for certain high risk patients, more drugs could cause higher toxicity, potentially leading to early discontinuation, or frequent interruptions, thereby diminishing the therapeutic effects of maintenance / protracted treatment.
While one could potentially use the same drug that was used in the induction regimen, particularly if the response to the induction regimen is good (for example, many patients in the CALGB trial of lenalidomide (Revlimid) maintenance had received Revlimid induction as well), maintenance therapy with a drug that is completely different from the original induction regimen allows a patient's myeloma cells to be exposed to new drug with a completely different mechanism of action.
Moreover, the risk of cumulative toxicity (such a neuropathy with bortezomib (Velcade), or risk of second cancers with cyclophosphamide or Revlimid) should be taken into account when considering the use of the same drug both during induction and maintenance phase.
Having said that, there are certain points to keep in mind before considering the type and duration of maintenance therapy.
Maintenance therapy in myeloma is given with the aim of prolonging overall survival and maintaining a person in remission for as long as possible, without causing significant side effects and compromising the quality of life..
Genetic features play an important role in determining the kind of therapy that should be used for maintenance. At Mayo Clinic, our approach for the 'standard-risk' patients, outside of clinical trials, is to give 2 cycles of consolidation with Revlimid post transplant to deepen the response, followed by maintenance therapy with Revlimid if a patient is Revlimid-responsive and not in at least a very good partial remission (VGPR). All such therapies are commenced post transplant only after discussing the pros and cons.
We do use Velcade as maintenance therapy (with or without Revlimid) if certain cytogenetic features [chromosomal abnormalities] are present. Long term consequences should also be discussed with the patients prior to embarking on maintenance.
While we do use combinations of Velcade and Revlimid as maintenance for certain high risk patients, more drugs could cause higher toxicity, potentially leading to early discontinuation, or frequent interruptions, thereby diminishing the therapeutic effects of maintenance / protracted treatment.
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Dr. Prashant Kapoor - Name: Prashant Kapoor, M.D.
Beacon Medical Advisor
Re: Using a drug from induction therapy for maintenance?
What about if initial therapy was melphalan and prednisone. My mother has had a partial response to this chemo. We will be checking markers again in a few weeks after she has finished this round of chemo, which is her 6th treatment.
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Tina Ellis
3 posts
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