In Dallas, Community Pharmacy Is Ready for Bispecifics in Myeloma. Hospitals and Prescribers Are Still Catching Up

The evidence supporting bispecific antibodies in early-relapse multiple myeloma has arrived faster than the infrastructure to deliver them close to home. That was the message from a Stakeholder Interchange presented August 4, 2026, by The American Journal of Managed Care® in Dallas, Texas, where academic myeloma specialists and community pharmacy managers discussed what it takes to bring teclistamab (Tecvayli), talquetamab (Talvey), both from Janssen, and related agents into community practice.

The session was moderated by Larry Anderson, MD, PhD, FACP, professor of medicine and director of the Myeloma, Waldenström's, and Amyloidosis Program at UT Southwestern Medical Center/Harold C. Simmons Comprehensive Cancer Center. He was joined by 2 colleagues from UT Southwestern: Aimaz Afrough, MD, assistant professor and medical director of the Blood Cancers/Transplant and Cellular Therapies Clinic, and Samer Al Hadidi, MD, MS, associate professor and clinical director of the Amyloidosis Program.

Four pharmacy leaders from Texas Oncology also participated. They were Daniel Min, PharmD, area pharmacy manager for the Northeast Dallas region; Samuel Chung, PharmD, pharmacy manager for the Flower Mound and Castle Hills sites; Ricardo Myers, PharmD, pharmacy manager, The US Oncology Network, Mesquite; and Jay Keele, PharmD, oncology pharmacy manager for Texas Oncology in Denison.

Second-Line Data Reset the Landscape

Anderson opened by highlighting the fact that the National Comprehensive Cancer Network (NCCN) now lists teclistamab plus daratumumab as a second-line option for patients with 1 prior line, based on MajesTEC-3; FDA approved the combination in March 2026.¹^˒² In that trial, 83.4% of patients receiving the combination were progression free at 3 years, compared with investigator's choice of daratumumab (Darzalex; Janssen) with pomalidomide (Pomalyst; Bristol Myers Squibb) and dexamethasone or bortezomib (Velcade; Takeda) dexamethasone. The response rate was about 89% and the rate of measurable residual disease (MRD) negativity was about 58%.³ Anderson cautioned that few MajesTEC-3 patients had prior CD38 exposure, unlike today's patients, most of whom have received daratumumab up front.

MajesTEC-9, presented at the American Society of Clinical Oncology annual meeting in June, addressed that gap. In patients with 1 to 3 prior lines, most of them CD38 exposed, teclistamab monotherapy produced an 18-month progression-free survival (PFS) rate of 69.8%, vs 26.9% with pomalidomide-bortezomib-dexamethasone or carfilzomib-dexamethasone. Grade 3/4 infections occurred in 41.6% of patients, cytokine release syndrome (CRS) in 66% (mostly grade 1), and immune effector cell–associated neurotoxicity syndrome (ICANS) in 4.1%.⁴ In MonumenTAL-3, which followed at the European Hematology Association (EHA) 2026 Congress, the 2-year PFS rate with talquetamab plus daratumumab was 77.6%, vs 51.2% with daratumumab-pomalidomide-dexamethasone.⁵ However, the GPRC5D-directed regimen brought taste changes in 74.8% of patients, weight loss in 38.3%, and ataxia or balance disorders in 12.4%.⁵

The case for using the best therapy rests on attrition, as fewer patients reach each subsequent line.⁶ Anderson cited a 5.4-fold increase in patient volume from the fifth line to the second.

“I am saying no one should die without a trial of BCMA [B-cell maturation antigen] therapy,” Anderson said. “We used to say without a trial of steroids, but now it is without a trial of some kind of BCMA therapy.”

"[In] the fifth line, it’s a completely different story. We're seeing two-thirds are responding, but then most relapse within a year,” Anderson added. “Whereas second line, the majority are in remission for 3 years.”

Step-Up Dosing Has Moved Ahead of the Label

The teclistamab label still calls for 48 hours of hospitalization after each of the first 2 step-up doses.⁷ In practice, Afrough said, UT Southwestern runs step-up dosing entirely in the clinic.

“The way that we are doing it at UT Southwestern is just we’re making it on weekdays. So, we never really catch the patient on a weekend,” she said. Teclistamab doses go on Monday and Wednesday, with the full dose the next Monday, so that “if the patient [is] going to have any problem, we're going to catch it early, in working hours, hopefully. So, then we don't need admission.”

Patients go home with a “pocket dex” plan: acetaminophen for a temperature of 100.4 °F or higher, dexamethasone if fever persists 2 hours later, and a visit for tocilizumab if it continues. So far, Afrough said, her patients have not needed to use the dexamethasone. Al Hadidi said that because bispecifics have long half-lives, label schedules are closer to suggestions, and clinicians can be “generous” with steroids in a way they cannot be with chimeric antigen receptor (CAR) T-cell therapy.

Anderson reviewed data supporting prophylactic tocilizumab. In the most recent update of the community-based OPTec study presented during ASCO, 8.9% of 45 patients receiving teclistamab developed CRS, all grade 1, and none were hospitalized.⁸ In a University of Miami series of 119 patients given tocilizumab before their first bispecific dose, CRS occurred in about 10% and ICANS in about 6%.⁹ Within the OneOncology network, 70% of patients who began step-up dosing as outpatients completed it without hospitalization.¹⁰ The National Comprehensive Cancer Network now says clinicians can consider prophylactic tocilizumab before the first dose of a bispecific therapy.¹

Al Hadidi argued that the term “CRS” was part of the problem. “For the most part, grade 1 is only about a fever,” he said. “But I think the name itself carries some fear. People say CRS is something bad—admission and so on. So I think the name, we should have probably chosen another name."

Hospitals See Cost, Not Opportunity

Texas Oncology sites mostly use a hybrid model, giving the drug in clinic and admitting patients for observation. Min said the sticking point is outside the practice. “I think the biggest obstacle that we have is the partnership that we kind of need to have, either making sure that the emergency room is able to carry [tocilizumab] or they know how to deal with CRS or ICANS,” he said.

In Denison, Keele said, the only regional hospital has turned the practice down twice. “When you need a room just for observation, they cannot bill for medications, they cannot bill services, they definitely cannot bill the medications that we're giving outpatient,” he said. “So, they do not see the financial incentive in giving us the room or partnering up.” A new chief executive officer has shown more interest, he added.

“We heavily lean on the Sammons Baylor Cancer Center as well as Medical City,” Myers said of the Dallas–Fort Worth area. “So, they'll do their step-up dosing there, and then once the patient is on maintenance dose, they’ll transfer [the patient back]."

The group discussed ways around the impasse, including storing practice-owned tocilizumab in a partner hospital’s emergency department (ED). Panelists put the cost of a tocilizumab dose at roughly $2000 to $3000, compared with $7000 to $8000 for a night in the hospital; one economic model found per-patient step-up costs were about $8800 lower with outpatient teclistamab plus prophylactic tocilizumab than with inpatient dosing.¹¹

"If you don’t have 24/7 coverage, I feel like you just need to do prophylactic toci," Afrough said. "No doubt about it, you just do it."

Getting it covered is another matter. One pharmacist said approval is “really 50/50,” and another said it improves when tocilizumab is built into the initial regimen authorization rather than requested as needed later, and when the payer’s preferred biosimilar is chosen. Texas Oncology is also rolling out remote monitoring through Canopy, which prompts patients to log their temperature every 4 hours and routes alerts through a triage nurse to on-call physicians.

The Prescriber Gap

For Myers, the barrier is inside the practice. “We wish. We are trying really hard. Our hospital is aligned with us to use bispecifics, but we haven’t had a patient yet," he said of second-line use. “We have younger doctors who are willing. We have older doctors who are not willing.”

Keele described the opposite situation. All 4 medical oncologists at his clinic are eager, but some infusion nurses were hesitant until manufacturer representatives provided in-services.

Al Hadidi said community oncologists once sent bispecific patients to academic centers because volume was low, but second-line approval means practices lose revenue with every referral. “As I always say, if you're not comfortable with bispecifics, you need to be comfortable with bispecifics,” he said. “There's no way around it in myeloma.”

He described bispecifics as “elderly-friendly,” noting that an 88-year-old patient tolerated teclistamab better than her prior combination regimens. Anderson said frailty, not age alone, drives his decision to admit; he planned to hospitalize a 92-year-old patient for her bispecific the following week.

Asked for their takeaways at the end of the session, both community pharmacists said they would change how they make the case. “I think if I tell them CRS is just more of a fever, and if you do prophylactic toci, that really comes down a whole lot," Chung said. Keele said he would take the hospital conversation on himself. “Before this session, I basically just let the doctors, the physicians, the practice directors handle the talk with the hospital, and maybe I should talk to my pharmacy colleagues on the other side at the hospital to get them on board with us.”

Infection Prevention and a Coding Fix

Anderson reviewed the registrational trials: CRS occurred in 72% of patients in MajesTEC-1, 58% in MagnetisMM-3, and about three-quarters in MonumenTAL-1, mostly low grade, but infections were common before preemptive immunoglobulin replacement became routine.¹²⁻¹⁴ UT Southwestern gives intravenous immunoglobulin (IVIG) monthly for at least 3 to 6 months with BCMA-directed bispecifics.

Texas Oncology pharmacists described a payer policy requiring IgG below 400 mg/dL, which does not account for the nonfunctional M protein that inflates measured IgG in many patients. The UT Southwestern faculty said that using ICD-10 code D80.6 (antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia) has virtually eliminated denials for them.¹⁵ They also recommended writing a standing communication order in the treatment plan, so that infusion staff do not hold IVIG based on the IgG level. Al Hadidi added vaccinations and granulocyte colony-stimulating factor support to the list, noting that relapsed myeloma itself carries high infection risk.

Equity, Sequencing, and Fixed Duration

None of the Texas Oncology sites represented was offering CAR T at the time of the interchange. “A lot of times they’re just only offered bispecifics, which is, I think, not fair for our patients,” Min said. “It doesn't matter where they live, they should be offered the best options possible.”

He said the practice aims eventually to build on its bispecific infrastructure to deliver some CAR T therapy in the outpatient setting.

Anderson outlined the sequencing argument: patients who relapse after BCMA CAR T can still respond to a BCMA bispecific, but loss of BCMA after bispecific therapy can make subsequent CAR T less effective. Al Hadidi countered that “sequencing is a sign of failure.” With teclistamab plus daratumumab, most patients remain in remission years later. Afrough offered an analogy: CAR T is buying a house, with a hard process but something you own; a bispecific is renting an apartment, easy to start, but the payments never stop.

That is why the faculty expect the field to move toward fixed duration regimens. All 3 second-line phase 3 trials dosed until progression. Topline MonumenTAL-6 results showed a PFS hazard ratio of 0.11 with teclistamab plus talquetamab,¹⁶ and newer targets, including the FcRH5-directed cevostamab and trispecific antibodies with monthly dosing, are advancing.¹⁷ Time-limited therapy, panelists said, would reduce cumulative infection and IVIG burden and could preserve BCMA CAR T for later.

“It's coming to a neighborhood near you,” Anderson said. “It's already here.”

References

1. NCCN Clinical Practice Guidelines in Oncology. Multiple myeloma, version 5.2026. Accessed October 21, 2026. https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf
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15. ICD-10-CM code D80.6: antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia. AAPC. Accessed October 21, 2026. https://www.aapc.com/codes/icd-10-codes/D80.6
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