Dosing Considerations, Care Team Handoffs for Bispecific Agents

A roundtable discussion, moderated by Thomas Martin, MD, Blood Cancers Today Associate Editor, of the University of California, San Francisco, focused on bispecific therapeutics for the treatment of multiple myeloma. Dr. Martin was joined by Ajay Nooka, MD, MPH, FACP; Ajai Chari, MD; and Angela Dispenzieri, MD.

In the next segment of the roundtable series, the panel discusses optimal dosing for teclistamab, as well as appropriate patient handoff to the community provider post-treatment.

Watch the next segment in this series.

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Dr. Martin: How are you guys doing dosing of teclistamab after the first few months? Do you go to a less than weekly dosing? How do you do it?

Dr. Nooka: In order for us to uniformly give these agents, what we’ve decided was to follow the same schedule in the first month, just like how we do the [bortezomib], so the bortezomib dosing of 1-4-8-11. We are using the first week 1-4-8 for all these. As we move forward after the first two months, so alternating it to every other month and after the first six months going on to a monthly basis. I see that there is adequate data that is being built up in order to see do you really need to hit so hard when you achieve a good response? This dosing schedule might allow us to minimize all the toxicities that Ajai was mentioning.

Dr. Martin: We do the same thing after two or three months, especially if they’re in response, we go to every other week dosing for a couple more months, maybe two or three months, and then to monthly pretty quickly. It’s nice to actually have to come just once a month for that therapy. I think there’s also new data that shows that perhaps there are less infections over time with less frequent administration. I think we’re all getting to that point where we have to do less frequent administration. When you guys send people to the community after you’ve treated them at your center for a while, any tidbits you give to the community docs? Any sign out, any handoff?

Dr. Dispenzieri: I’ll pass. No, because I haven’t really done a lot of handoff at this point. We’ve really sort of held onto a lot of our patients.

Dr. Martin: You keep them there for that.

Dr. Dispenzieri: But there is some starting but just people aren’t there yet.

Dr. Chari: Yeah, I don’t think the community was ready and up and running.

Dr. Martin: The Bay Area community is quite aggressive actually. We have done some of that in fact. Really what we tell them is what we just talked about over the time that you still have to worry about infections, you got to make sure that they take their prophylaxis and we continue; we actually follow CD4 cell counts and we do Pneumocystis jirovecii pneumonia prophylaxis. As long as their CD4 cell count is low, they remain on it and then acyclovir forever and plus a few months, three, maybe four months until they’re off that.

Dr. Dispenzieri: Nobody does antifungal. We don’t, but nobody does, which is different from a lot of other things. You treat your acute leukemias, your transplants, you’re doing antifungal, but that prolonged neutropenia isn’t there. It’s everything but…

Dr. Martin: Yeah, the incidence of neutropenia is quite high, but it is just short. It’s very short duration, so it’s not that big of a deal.