Hello!
My mother was diagnosed with multiple myeloma in November 2014. She underwent a successful stem cell transplant procedure in New Delhi in May / June 2015. The doctor has prescribed bortezomib / dex maintenance therapy every other week for 3 months, 90 days after the transplant. My mother used the same drug combination for induction therapy and had several side effects, such as appetite loss, neuropathy etc.
Reading through the forums here, it seems lenalidomide (Revlimid) is the most common maintenance therapy in the U.S. Looks like lenalidomide is now widely available in India too. Wondering why the doctor didn't prescribe that instead of bortezomib.
Any cases in India who are using lenalidomide for post stem cell transplant maintenance therapy?
Forums
Re: Lenalidomide for maintenance therapy in India?
Hi Shukla,
I tend to agree that Revlimid seems to be recommended more often than Velcade for maintenance in the USA. While maintenance remains a hotly debated and discussed subject on this forum, my specialist tends to utilize the same agent in maintenance that was used for initial treatment. See this article:
"Counterpoints: Do Patients With Multiple Myeloma Need Maintenance Treatment?," Clinical Advances in Hematology & Oncology, March 2015 (full text of article)
But be clear that Dr. Berenson doesn't utilize transplants, so his comments are in the context of a drug-only treatment approach.
Was your mom using subcutaneous injections of Velcade or intravenous Velcade when she developed neuropathy? Did the neuropathy go away with time? Revlimid is not without its own problems and dangers.
I tend to agree that Revlimid seems to be recommended more often than Velcade for maintenance in the USA. While maintenance remains a hotly debated and discussed subject on this forum, my specialist tends to utilize the same agent in maintenance that was used for initial treatment. See this article:
"Counterpoints: Do Patients With Multiple Myeloma Need Maintenance Treatment?," Clinical Advances in Hematology & Oncology, March 2015 (full text of article)
It is our recommendation that all patients who do not show disease progression should receive maintenance therapy with the same agents used during their treatment. One exception is chemotherapeutic agents, which should be discontinued. Maintenance agents are typically administered at lower doses or less frequently than therapeutic doses, or in combination with corticosteroids. For instance, bortezomib is given every other week instead of 4 times monthly and IMiDs are continued along with corticosteroids if corticosteroids were part of the patient’s treatment regimen.
But be clear that Dr. Berenson doesn't utilize transplants, so his comments are in the context of a drug-only treatment approach.
Was your mom using subcutaneous injections of Velcade or intravenous Velcade when she developed neuropathy? Did the neuropathy go away with time? Revlimid is not without its own problems and dangers.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Lenalidomide for maintenance therapy in India?
Multibilly,
Thank you for your detailed response and for sending over the link to the article about maintenance therapies. Although it mentions that maintenance therapy should be with the same drug as initial treatment, I don't know if it explains the reasoning behind the recommendation.
I tend to think if most people are using Revlimid maintenance, then its probably the better choice, but I may be wrong.
My mom was initially given bortezomib intravenously, which caused peripheral neuropahy after 3 cycles. So they switched her to subcutaneous bortezomib in the 4th cycle and continued that way during pre-ASCT maintenance. Post-ASCT maintenance is subcutaneous too. I hear subcutaneous administration is now the preferred method for bortezomib (Velcade)?
Thank you for your detailed response and for sending over the link to the article about maintenance therapies. Although it mentions that maintenance therapy should be with the same drug as initial treatment, I don't know if it explains the reasoning behind the recommendation.
I tend to think if most people are using Revlimid maintenance, then its probably the better choice, but I may be wrong.
My mom was initially given bortezomib intravenously, which caused peripheral neuropahy after 3 cycles. So they switched her to subcutaneous bortezomib in the 4th cycle and continued that way during pre-ASCT maintenance. Post-ASCT maintenance is subcutaneous too. I hear subcutaneous administration is now the preferred method for bortezomib (Velcade)?
Re: Lenalidomide for maintenance therapy in India?
Hello Shukla,
Revlimid has been the favored form of maintenance therapy in the U.S. for a number of reasons.
One, it's an oral treatment, which makes it more convenient for patients to take for longer periods of time.
Two, until subcutaneous administration of Velcade became common, it was difficult to administer Velcade to patients for extended periods of time, due to the increasing risk of peripheral neuropathy developing as patients are treated with the drug for longer and longer periods of time.
Three, and largely due to the first two reasons I just mentioned, there has been much more research into the potential benefit of Revlimid maintenance therapy than there has been research into Velcade maintenance therapy.
If you are thinking that the greater popularity of Revlimid maintenance therapy in the U.S. (versus India) has something to do with Revlimid not having been available for a very long time in India, I don't think that is the case. The drug has been available in India for many years.
Also, there are reasons having to do with the disease building up resistance to more than one drug that might lead a doctor to prescribe the same drug to a patient for both induction and maintenance therapy, rather than switching to another drug for maintenance.
Revlimid has been the favored form of maintenance therapy in the U.S. for a number of reasons.
One, it's an oral treatment, which makes it more convenient for patients to take for longer periods of time.
Two, until subcutaneous administration of Velcade became common, it was difficult to administer Velcade to patients for extended periods of time, due to the increasing risk of peripheral neuropathy developing as patients are treated with the drug for longer and longer periods of time.
Three, and largely due to the first two reasons I just mentioned, there has been much more research into the potential benefit of Revlimid maintenance therapy than there has been research into Velcade maintenance therapy.
If you are thinking that the greater popularity of Revlimid maintenance therapy in the U.S. (versus India) has something to do with Revlimid not having been available for a very long time in India, I don't think that is the case. The drug has been available in India for many years.
Also, there are reasons having to do with the disease building up resistance to more than one drug that might lead a doctor to prescribe the same drug to a patient for both induction and maintenance therapy, rather than switching to another drug for maintenance.
Re: Lenalidomide for maintenance therapy in India?
Shukla,
As usual, Ian makes some really great points and I can't disagree with them, nor do I know the reason that Dr B has this particular philosophy with regards to maintenance and if he follows it with all his patients.
Also keep in mind that Dr. B is just one specialist and there are many eminent multiple myeloma specialists out there that would readily only recommend one agent such as Revlimid for maintenance or only to do maintenance for a short period of time or to forego maintenance altogether.
My intention in responding to you was only to suggest that your mom's doctor at least has one peer that "might" agree with your doctor's approach. I should have made this more clear when I first responded to you.
Subcutaneous injection of Velcade (a proteasome inhibitor) is indeed the preferred method for bortezomib administration. Folks are hoping that ixazomib (an oral proteasome inhibitor that is sometimes referred to as "oral Velcade" and is in Phase 3 trials right now) may be available soon as a convenient pill form to use for maintenance when a proteasome inhibitor is desired.
As usual, Ian makes some really great points and I can't disagree with them, nor do I know the reason that Dr B has this particular philosophy with regards to maintenance and if he follows it with all his patients.
Also keep in mind that Dr. B is just one specialist and there are many eminent multiple myeloma specialists out there that would readily only recommend one agent such as Revlimid for maintenance or only to do maintenance for a short period of time or to forego maintenance altogether.
My intention in responding to you was only to suggest that your mom's doctor at least has one peer that "might" agree with your doctor's approach. I should have made this more clear when I first responded to you.
Subcutaneous injection of Velcade (a proteasome inhibitor) is indeed the preferred method for bortezomib administration. Folks are hoping that ixazomib (an oral proteasome inhibitor that is sometimes referred to as "oral Velcade" and is in Phase 3 trials right now) may be available soon as a convenient pill form to use for maintenance when a proteasome inhibitor is desired.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Lenalidomide for maintenance therapy in India?
Shukla,
I do not disagree with what the others have told you. I just want to add a thought that may be of use. You have not indicated whether your mother has any specific mutations. This may have influenced the doctor in choosing Velcade for her initial treatment and for maintenance. I, for example, was on Revlimid/dexamethasone for induction, but for maintenance I am on Velcade, which is administered subcutaneously every other week. I have the t(4;14) mutation, and Velcade is considered important in this context.
I do not disagree with what the others have told you. I just want to add a thought that may be of use. You have not indicated whether your mother has any specific mutations. This may have influenced the doctor in choosing Velcade for her initial treatment and for maintenance. I, for example, was on Revlimid/dexamethasone for induction, but for maintenance I am on Velcade, which is administered subcutaneously every other week. I have the t(4;14) mutation, and Velcade is considered important in this context.
Re: Lenalidomide for maintenance therapy in India?
Mrozdav,
Good point.
Not to get off topic from Shukla's post, but if Velcade is warranted for t(4;14) patients, why didn't you use Velcade for induction as well? Did the mutation show up after induction?
Good point.
Not to get off topic from Shukla's post, but if Velcade is warranted for t(4;14) patients, why didn't you use Velcade for induction as well? Did the mutation show up after induction?
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Lenalidomide for maintenance therapy in India?
Mutlibilly,
I participated in a clinical trial which substituted a monoclonal antibody for the Velcade. My response was very deep, but after nine months I still showed a faint band on the IFE. At that point Velcade was added and I quickly reached a complete response. I did not have a stem cell transplant and so am depending on the Velcade maintenance at this point.
I participated in a clinical trial which substituted a monoclonal antibody for the Velcade. My response was very deep, but after nine months I still showed a faint band on the IFE. At that point Velcade was added and I quickly reached a complete response. I did not have a stem cell transplant and so am depending on the Velcade maintenance at this point.
Re: Lenalidomide for maintenance therapy in India?
mrozdav,
Got it. Thanks!
Got it. Thanks!
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Lenalidomide for maintenance therapy in India?
Thanks for the additional comments, Multibilly and Mrozdav.
Just to clarify, my comments about Revlimid maintenance were not meant to come across as advocating it versus, for example, Velcade maintenance. I just wanted to explain why it's been more popular in the States compared to Velcade maintenance.
In general when it comes to Revlimid maintenance, people need to remember that only one of three major trials that has compared Revlimid maintenance to placebo has actually found an overall survival benefit for Revlimid maintenance, and that one trial was probably the most flawed of the three trials in terms of its design. People in the trial that showed a survival advantage were recruited to participate in the trial AFTER they had undergone initial treatment for their newly diagnosed myeloma. So if you were a patient who was treated with Revlimid initially, and did not respond very well to it, you were probably not going to be very interested in participating in a Revlimid maintenance trial.
In contrast, the one study of the three that comes closest to duplicating the sort of treatment common in the States these days – the French "IFM" Revlimid maintenance trial – continues to show no overall survival benefit to Revlimid maintenance therapy. It also shows the sort of results you would expect with maintenance therapy; namely, patients who got Revlimid maintenance therapy had shorter progression-free survival from the treatment they received after Revlimid maintenance.
Not surprisingly, you don't hear as much about the IFM trial results these days because, I suspect, the trial investigators aren't getting as much financial support to write updates about it compared, for example, to the investigators leading the one (flawed) trial that is showing an overall survival benefit.
Just to clarify, my comments about Revlimid maintenance were not meant to come across as advocating it versus, for example, Velcade maintenance. I just wanted to explain why it's been more popular in the States compared to Velcade maintenance.
In general when it comes to Revlimid maintenance, people need to remember that only one of three major trials that has compared Revlimid maintenance to placebo has actually found an overall survival benefit for Revlimid maintenance, and that one trial was probably the most flawed of the three trials in terms of its design. People in the trial that showed a survival advantage were recruited to participate in the trial AFTER they had undergone initial treatment for their newly diagnosed myeloma. So if you were a patient who was treated with Revlimid initially, and did not respond very well to it, you were probably not going to be very interested in participating in a Revlimid maintenance trial.
In contrast, the one study of the three that comes closest to duplicating the sort of treatment common in the States these days – the French "IFM" Revlimid maintenance trial – continues to show no overall survival benefit to Revlimid maintenance therapy. It also shows the sort of results you would expect with maintenance therapy; namely, patients who got Revlimid maintenance therapy had shorter progression-free survival from the treatment they received after Revlimid maintenance.
Not surprisingly, you don't hear as much about the IFM trial results these days because, I suspect, the trial investigators aren't getting as much financial support to write updates about it compared, for example, to the investigators leading the one (flawed) trial that is showing an overall survival benefit.
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