Drug Topics - January 28, 2008 - (Page 10) 10 DRUG TOPICS JANUARY 28, 2008 www.drugtopics.com Rx Care NCCN issues guideline update for multiple myeloma Heidi Belden, Pharm.D. n October, the National Comprehensive Cancer Network (NCCN) released an updated version of its practice guidelines for multiple myeloma (MM). As part of the revision, NCCN added a new category 1 recommendation for patients with relapsed/refractory multiple myeloma. Bortezomib (Velcade, Millennium Pharmaceuticals), in combination with pegylated liposomal doxorubicin (Doxil, OrthoBiotech), is now recommended as a salvage therapy for MM patients in three clinical situations: progressive disease following allogeneic or autologous stem cell transport (SCT), primary progressive disease following initial autologous or allogeneic SCT, and non-transport candidates with progressive or relapsing disease after initial induction therapy. The combination therapy is now preferred to single agent bortezomib for salvage treatment. I thalidomide regimens as first line, they could then be treated with lenalidomide/dexamethasone when they relapse, he explained. However, the new update mentions that the NCCN panel was awaiting publication of two Phase III studies prior to designating the combination of lenalidomide/dexamethasone as a category 1 recommendation, so perhaps yet another update will be forthcoming. “Of course, it is important to note that lenalidomide/dexamethasone displayed better outcomes compared to dexamethasone alone regardless of prior thalidomide exposure,” Herrington added. Other recommendations Other new additions to the guide include a category 2b recommendation for a bortezomib/thalidomide/dexamethasone combination for primary induction therapy for transplant as well as a dexamethasone/cyclophosphamide/etoposide/cisplatin (DCEP) regimen as an option for salvage therapy. According to Herrington, paFirst-line treatment tients with a history of venous The issue of which treatment is best for thromboembolism may be less susfirst-line refractory disease is an interestceptible to recurrence when treated Multiple myeloma cells ing question, according to Jon D. Herwith a bortezomib/pegylated liporington, Pharm.D., BCPS, BCOP, an assistant professor somal doxorubicin combination than with thalidomide of medicine at Texas A&M University College of Med- and its analogs. Also, if patients are susceptible to dexicine. “There have also been two new articles looking at amethasone-induced adverse effects such as hyperthe use of lenalidomide (Revlimid, Celgene)/dexam- glycemia, the use of a non-steroid regimen like borteethasone for first-line treatment of relapsed/refractory zomib, with or without the doxorubicin, may be MM,” he said. “I think both regimens are potential op- beneficial. tions, especially since they each possess different adAnother interesting question is which bisphosphoverse-effect profiles.” nate to use to prevent fractures in MM patients, HerHerrington described a recent article in NEJM rington said. “Based on results from Zervais et al., the (Dimopoulos et al.) that demonstrated better out- use of zoledronic acid (Zometa, Novartis) produces a comes (survival and response rate) for those patients 9.5-fold increased risk of osteonecrosis of the jaw comwho never received thalidomide (Thalomid, Cel- pared with pamidronate,” he pointed out. “Many physigene) in the primary treatment of MM before they cians are now using pamidronate for skeletal fracture relapsed and were subsequently treated with prophylaxis instead of zoledronic acid.” However, in the lenalidomide. A strategy for some patients treated new NCCN guide, both agents have been added as opinitially with thalidomide might be combination tions for adjunctive treatment of bone disease. therapy with bortezomib/pegylated liposomal doxThe new NCCN multiple myeloma guide can be acorubicin upon relapse and for patients not receiving cessed at www.nccn.org. DT http://www.drugtopics.com http://www.nccn.org
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