A small study out of Sweden adds to context to the puzzle of how best to treat patients with multiple myeloma who contract COVID-19.
Patients with multiple myeloma (MM) or its precursor, smoldering MM, had worse survival outcomes when diagnosed with coronavirus disease 2019 (COVID-19) if they had progressive MM or were in remission with lenalidomide (Revlimid)-based combination therapies, according to a new report.
The paper, published in the European Journal of Haematology, highlights the experiences of 9 patients with COVID-19 symptoms who had undergone immunomodulatory therapies with daratumumab (Darzalex) or lenalidomide (Revlimid)-based combination treatments. All of the patients had been previously diagnosed with MM (8 patients) or smoldering MM (1 patient) at the time they began experiencing COVID-19 symptoms between March and May of this year.
Six patients with MM were on daratumumab-based therapy, and 2 were on lenalidomide-dexamethasone (RD). All patients had a fever at presentation, and all but one reported a dry cough. PCR tests were later used to confirm the COVID-19 diagnosis. Physicians ceased all MM treatments once the symptoms were identified.
Four of the patients died within 3 weeks of their first symptoms, including 2 with progressive disease and 2 who were in remission. The 2 patients with progressive disease were being treated with daratumumab within 3 weeks of the onset of COVID-19 symptoms. The 2 patients in remission had received RD therapy.
Of the 5 surviving patients, the patient with SMM developed IgM antibodies after the start of COVID-19 symptoms, but they did not seroconvert to IgG. Just 1 of the 3 other patients on daratumumab had an IgG response. The 5 surviving patients were all able to resume their daratumumab-based therapies once COVID-19 symptoms abated, even though they still had positive PCR responses.
Corresponding author Katharina Susek, MD, of the Karolinska Institute, in Sweden, and colleagues noted that immunoparesis was observed in all of the patients treated with daratumumab, but it did not appear to correlate with survival. Instead, they wrote that other factors seemed to be linked with lower survival rates.
“With the limitation of a low study subject number, we observed that patients with progressive disease seem to be at higher risk for mortality from COVID-19 as were patients in remission on RD treatment,” they wrote.
It is possible that the correlation is due to dysregulation of the immune system during progression, or simply to the nature of immunomodulatory therapies. These hypotheses would need to be confirmed in larger studies, they wrote.
In an email to The American Journal of Managed Care®, Susek said given the still-limited knowledge of COVID-19 in MM, prevention of the infection ought to remain a focus for clinicians.
“So far, general recommendations of personal hygiene (eg, regular handwashing) and social distancing are encouraged among all patients,” she said.
As for whether or not to suspend or change therapy, Susek noted that several consensus guidelines have been published. However, she said ultimately such decisions will need to be highly patient-specific.
“It is possible that certain therapies are postponed or therapies adapted,” she said. “However, treatment decisions need to be made on an individual basis with a careful consideration of risks versus benefits of MM treatment during the pandemic.”
Susek KH, Gran C, Ljunggren HG, Alici E, Nahi H. Outcome of COVID-19 in multiple myeloma patients in relation to treatment. Eur J Haematol. Published online August 3, 2020. doi:10.1111/ejh.13502