Clinicians treating patients with multiple myeloma have a number of factors to consider as they treat patients in an era of high-risk COVID-19 infection.
The coronavirus disease 2019 (COVID-19) pandemic has forced clinicians to rethink much of how they go about their daily work, but how should that translate into therapeutic decisions for patients with complicated diseases like multiple myeloma (MM)?
Corresponding author Morie A. Gertz, MD, of the Mayo Clinic, in Rochester, Minnesota, said oncologists are well aware that their cancer patients are in a heightened risk category for COVID-19. For one thing, patients on active chemotherapy have significant immunosuppression, he said, making them less likely to be able to fight off infection. The issue they must confront is whether and how to change patients’ treatment plans.
“The piece was designed for oncologists treating myeloma patients to reference options to defer therapy or substitute therapy that would not require frequent visits to a medical center with many ill patients,” he told The American Journal of Managed Care®.
Gertz and colleagues say there are ways in which MM patients in particular are at particularly high risk due to COVID-19. One is the fact that MM tends to be diagnosed at an older age (the mean age at diagnosis is 65), a demographic group that is also at a higher risk of severe disease. Patients who have lymphopenia at diagnosis are at a higher risk of infection due to the suppression of normal B-cell development and function. Decreased CD+4 T-cell counts at diagnosis also increase the risk of infection at diagnosis, among other factors, Gertz and colleagues write.
The authors do not recommend therapy in the cases of patients with smoldering myeloma, whether standard or high risk. Instead, they say close monitoring and observation is the best approach for such patients in the current environment.
All newly diagnosed patients ought to be screened for COVID-19 before any therapy, the investigators write, noting that the cancer can aggravate the adverse events of the infection.
“For patients testing positive for COVID-19 we recommend holding treatment until they have convalesced from acute illness,” Gertz and colleagues say. “Metabolic and bone-related acute complications can be best managed with supportive care.”
For patients with standard risk, the authors suggest ixazomib, lenalidomide, and dexamethasone (IRd) given over a 28-day cycle as the preferred option. Other possible combinations are cyclophosphamide lenalidomide and dexamethasone (CRd); daratumumab lenalidomide and dexamethasone (DRd); lenalidomide, bortezomib, and dexamethasone (RVd); or cyclophosphamide, bortezomib, and dexamethasone (CyBorD).
For high-risk patients, Gertz and colleagues recommend carfilzomib, lenalidomide, and dexamethasone (KRd) or RVd, with the former as the preferred option. They also recommend decreasing the dose of dexamethasone to 20 mg and giving bortezomib subcutaneously once a week.
“We recommend delaying autologous stem cell transplant (ASCT), unless the patient has high-risk disease that is not responding well, or if the patient has plasma cell leukemia (PCL),” they write, noting again, that patients ought to be tested for COVID-19 prior to transplantation.
After 10-12 cycles, Gertz and colleagues say lenalidomide is the recommended maintenance therapy for standard-risk patients, and bortezomib or ixazomib are preferred for high-risk patients. Relapsed patients should be given daratumumab-based regimens, but routine ASCT should be postponed until after the epidemic, unless the patient has an aggressive relapse or secondary plasma-cell leukemia.
Al Saleh AS, Sher T, Gertz MA. Multiple myeloma in the time of COVID-19. Acta Haematologica. 2020:1-7. doi:10.1159/000507690