What Are the Treatment Options for Patients With Lenalidomide-Refractory Myeloma?

Donna Catamero, ANP-BC, OCN, CCRC, of the Icahn School of Medicine at Mount Sinai, discusses the efficacy and toxicity management of selinexor (XPOVIO), results from the BOSTON trial, and other recent advances in multiple myeloma (MM) treatment and research.

Catamero first reflected on the new updates to the National Comprehensive Cancer Network (NCCN) guidelines, which recommend against recycling anti-CD38 monoclonal antibodies. The NCCN also recommends introducing different classes of therapies in the relapsed setting.

While recycling daratumumab and other anti-CD38 monoclonal antibodies is still being practiced, Catamero said that introducing different classes of therapies when patients are refractory to lenalidomide is already being done in practice.

“I really think the NCCN is reflecting what we’re doing in practice,” she said. “I’m happy to see that they have supportive care guidelines, especially for infections.”

Next, Catamero described the efficacy, toxicity, dosing, and accessibility of oral selinexor.

“Selinexor remains a great option for patients even after one prior line of therapy,” Catamero began, noting that the drug has a 70% response rate in the lenalidomide-refractory setting. “As a practice, we’re not starting patients at the highest dose of 100 mg. It’s important with this regimen to start low and go slow. If we want success on this regimen, we really need to titrate the dose to a patient’s tolerance.”

The side effects of selinexor are dependent on dose, Catamero said, and include gastrointestinal side effects like nausea, vomiting, and diarrhea.

“Prior to initiating selinexor, I make sure that my patients have two antiemetics at home,” she explained. “Usually, I’m going to prescribe ondansetron and Zyprexa to manage the nausea. With ondansetron and a lower dose, I’m managing patients quite well on [selinexor].

Next, Catamero described the key takeaways from the BOSTON trial, which compared once-per-week selinexor, bortezomib, and dexamethasone (XVd) with twice-per-week bortezomib and dexamethasone (Vd) in patients with MM. The progression-free survival (PFS) was 9.5 months in the Vd group, compared with 13.9 months in the XVd group.

“We did see a significant PFS in that triplet with selinexor, bortezomib, and dexamethasone, and we did see some deep responses,” Catamero said.