Starting my first round of RVD (Revlimid, Velcade, and dexamethasone) very soon.
Want to understand more about how dosages are determined. I am starting on (at least) four 21-day cycles (2 weeks on, 1 week off). Revlimid at 25 mg, dex at 40 mg. My understanding is that I will be monitored closely, and that my dose will be 'adjusted as needed'.
How is the 'optimal dose' for a patient generally determined? What are common criteria for adjusting dosages up (or down)?
Is this 'art' as much as 'science'?
Thanks
RT
Forums
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RadiantTiger - Name: Radiant Tiger
- Who do you know with myeloma?: Myself, my deceased uncle
- When were you/they diagnosed?: Feb 2015
- Age at diagnosis: 54
Re: RVD - how is the dosing for a patient selected?
Velcade is dosed at 1.3mg/sq meter of body surface area 2x / week, 2 weeks on 1 week off. The Velcade is a either an IV or subcutaneous. The subq dose seems to have fewer side effects (neuropathy) than the IV dose. Alpha lipoic acid can be used to help with the neuropathy. Gabapentin can also help if you have any neuropathy.
Dexamethasone is started at 40 mg 2x per week, 2 weeks on 1 week off. It is an infusion.
The Revlimid is adjusted to be as high a dose as you can tolerate starting at 25 mg/day. My wife, who is on Revlimid and dex as a maintenance drug, had trouble with the 25 mg dose. It made her very tired around 3 pm, and she basically went to sleep. We have adjusted her dose to 15 mg and that worked for a few months and then she started getting tired around 8 pm. Now we have a 10 mg dose, and hopefully she will not be falling asleep. She is taking Revlimid for 21 days on and 7 days off but that is for maintenance therapy.
My wife has (had) kappa light chain myeloma, and it caused lesions in her bones and a lot of pain. We started off with the Velcade and dex but with Zometa (zolodronic acid) to strengthen her bones. She had a stringent complete response! BUT EVERYONE IS DIFFERENT.
Personally I think that the Velcade/dex/Revlimid is great (and very expensive) but it is an effective first course of action.
Eat well and DRINK LOTS OF WATER to help keep your kidneys in good shape - very important your body will be getting rid of a lot of myeloma cells and your kidneys will be doing a lot of work.
Dexamethasone is started at 40 mg 2x per week, 2 weeks on 1 week off. It is an infusion.
The Revlimid is adjusted to be as high a dose as you can tolerate starting at 25 mg/day. My wife, who is on Revlimid and dex as a maintenance drug, had trouble with the 25 mg dose. It made her very tired around 3 pm, and she basically went to sleep. We have adjusted her dose to 15 mg and that worked for a few months and then she started getting tired around 8 pm. Now we have a 10 mg dose, and hopefully she will not be falling asleep. She is taking Revlimid for 21 days on and 7 days off but that is for maintenance therapy.
My wife has (had) kappa light chain myeloma, and it caused lesions in her bones and a lot of pain. We started off with the Velcade and dex but with Zometa (zolodronic acid) to strengthen her bones. She had a stringent complete response! BUT EVERYONE IS DIFFERENT.
Personally I think that the Velcade/dex/Revlimid is great (and very expensive) but it is an effective first course of action.
Eat well and DRINK LOTS OF WATER to help keep your kidneys in good shape - very important your body will be getting rid of a lot of myeloma cells and your kidneys will be doing a lot of work.
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caregiver
Re: RVD - how is the dosing for a patient selected?
Tomorrow will be my second cycle of RVD. I am on 15 mg of Revlimid, and 40 mg of dexamethasone. I also am 2 weeks on and 1 week off.
Revlimid 15 mg once a day for 2 weeks
Velcade injection on day 1 and day 8 with day 15 off
Dexamethasone 40 mg on day of Velcade injection day 1 and day 8 with day 15 off
I drink about 2 liters of water everyday. So far I have not had any side effects. Except on days of dexamethasone,I can get to sleep but only sleep for about 5 hours. No fatigue or nausea. I exercise every day at least 30 minutes on the spin bike.
I think a good diet, lots of water and exercise will help with side effects of meds. Good luck to you.
Revlimid 15 mg once a day for 2 weeks
Velcade injection on day 1 and day 8 with day 15 off
Dexamethasone 40 mg on day of Velcade injection day 1 and day 8 with day 15 off
I drink about 2 liters of water everyday. So far I have not had any side effects. Except on days of dexamethasone,I can get to sleep but only sleep for about 5 hours. No fatigue or nausea. I exercise every day at least 30 minutes on the spin bike.
I think a good diet, lots of water and exercise will help with side effects of meds. Good luck to you.
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Mary D
Re: RVD - how is the dosing for a patient selected?
I would be asking to use Mary's suggestion on the once-a-week dex schedule. 40 mg given once a week instead of more frequently is pretty much the new standard and causes less complications than the older "high dose" schedule. In the case of dex, it has been shown that "less is more" in some recent studies (with "less" being based on dose schedule, not dosage amount). Apparently infusion of dex (as Caregiver mentions) can also help minimize side effects
You might want to read through this thread for some more discussions on this.
"Dexamethasone can be given over two days," forum disc. started Nov 14, 2014.
You might want to read through this thread for some more discussions on this.
"Dexamethasone can be given over two days," forum disc. started Nov 14, 2014.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: RVD - how is the dosing for a patient selected?
After reading from The Myeloma Beacon, it's clear everyone is treated differently, depending on the doctor and or the place of treatment.
I could not tolerate the 25 mg due to severe rash so it was dropped to 5 mg. After my transplant, I was started on a 28-day cycle with the Revlimid, dex 8 mg orally and Velcade subq based on weight, I think. Revlimid on days 1-21. Velcade on days 1-8-15. Dex on shot days. Off 7 days.
I have been on this for 3 years and am going back to UAMS next week and expect to be taken off all meds except for Zometa, which I've been taken for a year (I get it on week one, only time I see the doctor during the month). My numbers have been on the low side of normal.
The only side effect is neuropathy, which I'm taking gabapentin 900 mg daily for. When I mentioned the neuropathy last year, my doctor cut the Velcade to 80% of normal.
Hope this helps. I'm 72 and was never sick a day in my life until multiple myeloma. But now, with all the different treatments available and the research going on, I certainly don't think myeloma will do me in
I could not tolerate the 25 mg due to severe rash so it was dropped to 5 mg. After my transplant, I was started on a 28-day cycle with the Revlimid, dex 8 mg orally and Velcade subq based on weight, I think. Revlimid on days 1-21. Velcade on days 1-8-15. Dex on shot days. Off 7 days.
I have been on this for 3 years and am going back to UAMS next week and expect to be taken off all meds except for Zometa, which I've been taken for a year (I get it on week one, only time I see the doctor during the month). My numbers have been on the low side of normal.
The only side effect is neuropathy, which I'm taking gabapentin 900 mg daily for. When I mentioned the neuropathy last year, my doctor cut the Velcade to 80% of normal.
Hope this helps. I'm 72 and was never sick a day in my life until multiple myeloma. But now, with all the different treatments available and the research going on, I certainly don't think myeloma will do me in
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James S - Name: James Szalay
- Who do you know with myeloma?: Self
- When were you/they diagnosed?: Nov. 2010
- Age at diagnosis: 68
Re: RVD - how is the dosing for a patient selected?
Mary D - Great to hear that not everyone has a lot of side effects. I am most concerned about GI issues, since I've always had a sensitive gut.
Thanks everyone, for your responses. It seems like dosages are adjusted based on side affects. I will drink lots of water!
Thanks everyone, for your responses. It seems like dosages are adjusted based on side affects. I will drink lots of water!
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RadiantTiger - Name: Radiant Tiger
- Who do you know with myeloma?: Myself, my deceased uncle
- When were you/they diagnosed?: Feb 2015
- Age at diagnosis: 54
Re: RVD - how is the dosing for a patient selected?
Hi everyone,
Back in the day (2013) when I was on RVD therapy, I took dex by pill 10 mg 4 days per week. It's interesting and encouraging to see how the recommended administration (IV instead of oral) and dosing schedule (1 time per week) have changed just in a couple of years to reduce side effects.
Also at that time, sub q administration of Velcade (instead of IV) to reduce peripheral neuropathy was a brand new thing.
I take these as just a couple small signs of the progress that is being made in dealing with multiple myeloma.
Mike
Back in the day (2013) when I was on RVD therapy, I took dex by pill 10 mg 4 days per week. It's interesting and encouraging to see how the recommended administration (IV instead of oral) and dosing schedule (1 time per week) have changed just in a couple of years to reduce side effects.
Also at that time, sub q administration of Velcade (instead of IV) to reduce peripheral neuropathy was a brand new thing.
I take these as just a couple small signs of the progress that is being made in dealing with multiple myeloma.
Mike
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mikeb - Name: mikeb
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2009 (MGUS at that time)
- Age at diagnosis: 55
Re: RVD - how is the dosing for a patient selected?
I am on a 2 week on, one week off cycle, 25 mg Revlimid days 1-14; 20 mg dex and Velcade (subcutaneous injection) on days 1, 4, 8 and 11. Am about to start my third cycle on Monday. My specialist (Dana Farber) said it would be 2-4 cycles, the treating clinician (Smilow/Yale) said 4-6, so I guess we will see ...
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heatherlib - Name: heather
- Who do you know with myeloma?: self
- When were you/they diagnosed?: may 2014
- Age at diagnosis: 52
Re: RVD - how is the dosing for a patient selected?
From what I've heard here in the forum and from speaking with myeloma patients and doctors, most myeloma specialists use dosing regimens that match those used in the better known trials of whatever regimen they are recommending. They also tend to follow the approach used in most trials, which is to start patients on a standard dose and then reduce the dose, as necessary, if side effects occur.
One other thing ... I think it was mentioned somewhere that myeloma specialists are more frequently using dex doses of less than 20 mg per week. Maybe this is true, but it's news to me. Just as an example, in the trial that is planned for Revlimid, daratumumab, and dex in newly diagnosed myeloma patients, the dose of dex will be 40 mg per week,
https://clinicaltrials.gov/ct2/show/NCT02252172
Also, in the key study that showed that "lower dose" dex is better, in terms of survival, than older, higher doses of dex, the "low dose" of dex was 40 mg once every week throughout the course of therapy. The high dose was 40 mg given once per day, 4 days a week, for 3 out of every 4 weeks.
SV Rajkumar et al, "Lenalidomide plus high-dose dexamethasone versus lenalidomide plus low-dose dexamethasone as initial therapy for newly diagnosed multiple myeloma: an open-label randomised controlled trial," Lancet Oncology, Jan 2010 (full text at PubMed).
One other thing ... I think it was mentioned somewhere that myeloma specialists are more frequently using dex doses of less than 20 mg per week. Maybe this is true, but it's news to me. Just as an example, in the trial that is planned for Revlimid, daratumumab, and dex in newly diagnosed myeloma patients, the dose of dex will be 40 mg per week,
https://clinicaltrials.gov/ct2/show/NCT02252172
Also, in the key study that showed that "lower dose" dex is better, in terms of survival, than older, higher doses of dex, the "low dose" of dex was 40 mg once every week throughout the course of therapy. The high dose was 40 mg given once per day, 4 days a week, for 3 out of every 4 weeks.
SV Rajkumar et al, "Lenalidomide plus high-dose dexamethasone versus lenalidomide plus low-dose dexamethasone as initial therapy for newly diagnosed multiple myeloma: an open-label randomised controlled trial," Lancet Oncology, Jan 2010 (full text at PubMed).
Re: RVD - how is the dosing for a patient selected?
I seem to be on another programme. I have just started my 4th cycle of VMP.
1.79 Velcade (bortezomib), reduced to 1.3 because of neuropathy, and tolerating this dosage well), once a week for two weeks, one week off and then again once a week for two weeks.
As well, 8 mg increased to 10 and now the desired dosage of 12 mg of melphalen for the first 4 days of the cycle.
Snd also 100 mg prednisone for 4 days. So far I did tolerate the prednisone, However, last week I experienced a psychotic episode and will have to address this on my next check-up.
Any suggestions? I have learned an enormous amount from your site, for which I thank you all.
1.79 Velcade (bortezomib), reduced to 1.3 because of neuropathy, and tolerating this dosage well), once a week for two weeks, one week off and then again once a week for two weeks.
As well, 8 mg increased to 10 and now the desired dosage of 12 mg of melphalen for the first 4 days of the cycle.
Snd also 100 mg prednisone for 4 days. So far I did tolerate the prednisone, However, last week I experienced a psychotic episode and will have to address this on my next check-up.
Any suggestions? I have learned an enormous amount from your site, for which I thank you all.
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Doingit
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