T-Bird (thalidomide, clarithromycin/[Biaxin®], lenalidomide/[Revlimid®], Dexamethasone) Therapy for Upfront Use in Symptomatic Multiple Myeloma.

BiRD therapy (clarithromycin/[Biaxin®], lenalidomide/[Revlimid®], dexamethasone) for use as upfront therapy in symptomatic multiple myeloma in 72 patients yielded impressive results: over 90% achieved at least a partial response (PR), with nearly 40% in complete response (CR). We hypothesized that we could safely increase the immunomodulatory benefit of the BiRD combination with the addition of low-dose thalidomide to the regimen, since these drugs have non-overlapping toxicities. A trial of T-BiRD (thalidomide, clarithromycin/[Biaxin®], lenalidomide/[Revlimid®], dexamethasone) therapy for use in up-front treatment of symptomatic multiple myeloma (MM) was initiated to test safety and efficacy.

Eighteen patients were enrolled in a single-institution trial of T-BiRD therapy for symptomatic MM. The T-BiRD regimen consists of clarithromycin 500mg twice daily, dexamethasone on days 1,8,15,22 of a 28-day cycle, and lenalidomide 25mg for days 1–21 of a 28-day cycle. Thalidomide is given at a dose of 50mg daily for the first week and thereafter at 100mg daily. Thromboprophylaxis with aspirin (162 mg once weekly, 81mg on subsequent days) was used for all subjects. Serum protein electrophoresis/immunofixation as well as free light chain determinations were done monthly. Bone marrow biopsy and either skeletal imaging were done at to confirm disease progression or CR. This protocol continues to accrue with a planned enrollment of 25 patients.

The median number of T-BiRD cycles was 5.5 (range 1–6). Twelve patients (67%) had achieved at least a partial response (PR) by cycle 1, compared to a median response time of 2 cycles for BiRD. Mean percent drop in M-protein for evaluable patients at each cycle is as follows: Cycle 1 – 61%, Cycle 2 – 77%, Cycle 3 – 79%, Cycle 4 – 81%, Cycle 5 – 93%, Cycle 6 – 92%. For 9 subjects who received 5 cycles of therapy, the overall response rate was 100%, with all but one subject achieving a VGPR or better. On an intent to treat basis, the VGPR or better rate was 55% because of patient withdrawal due to toxicity. A total of 10 subjects (56%) experienced an adverse event (AE), some study-drug related (RAE) during treatment. Seven subjects (39%) withdrew from the study due to drug toxicity: 2 had grade 2 skin rash prior to initiation of full-dose thalidomide (RAE), 1 patient had grade 4 skin rash (Stevens-Johnsons syndrome, SJS) during cycle 1 of T-BiRD (RAE), 1 had a TIA in cycle 2, 1 developed renal failure in cycle 1, 1 developed chest pain in cycle 3. Other toxicities include 1 patient with Grade 2 steroid myopathy (RAE), 1 patient with DVT of the leg (RAE), and 1 patient with atrial fibrillation. 1 subject died of progressive myeloma prior to completion of 1 cycle.

T-BiRD is a highly effective first-line regimen for rapid and profound treatment response of multiple myeloma. Toxicity from T-BiRD may preclude its long-term use since many of the enrolled patients experienced an adverse event.

Mark:Celgene: Research Funding, Speakers Bureau. Zafar:Celgene Corp: Speakers Bureau; Millenium: Speakers Bureau. Crann:Milllennium: Membership on an entity's Board of Directors or advisory committees. Niesvizky:Celgene: Consultancy, Research Funding, Speakers Bureau; Millennium Pharmaceuticals, Inc.: Consultancy, Research Funding, Speakers Bureau; Proteolix: Consultancy, Research Funding.