Table 1. Factors to consider when... | American Society of Hematology

Table 1.

Factors to consider when selecting the next line of therapy in patients with relapsed MM

Prior MM directed therapies (induction/first line)	MM disease risk stratification	Patient conditions
Triplet vs quadruplet therapy • Triplet o DRd vs RVd • Quadruplet ○ D-RVd^* ○ Clinical trial	High risk vs standard risk • Cytogenetics ○ Hypoploidy ○ Hyperploidy • Fluorescence in situ hybridization ○ Del 17p, t(4;14), t(14; 16), t(14;20), gain 1q, loss 1p • Next-generation sequencing • Genomic expression profiling	Renal disease • Cast nephropathy • Nonmalignant etiology • Severity • Medication toxicity
Alkylator^† • Bendamustine • Cyclophosphamide Anthracycline • Doxorubicin • Doxil	Time to relapse • Early (<12 mo vs <24 mo) • Late (>48 mo) • Slow (asymptomatic/biochemical) • Rapid (symptomatic)	Neuropathy • MM related • Nonmalignant etiology
Proteasome inhibitor • Bortezomib • Carfilzomib • Ixazomib	Extramedullary disease • Plasmacytomas ○ Visceral ○ Skin • Central nervous system disease	Bone lesions (symptomatic vs asymptomatic)
ASCT • Transplant ineligible • Transplant eligible	Peripheral blood plasma cells • <5% • >5% • >20%	Steroid (tolerant vs intolerant)
Institutional/resources • Advanced cancer care center • Community medical center		Non-MM-related health conditions • Cardiovascular • Renal disease

Prior MM directed therapies (induction/first line)	MM disease risk stratification	Patient conditions
Triplet vs quadruplet therapy • Triplet o DRd vs RVd • Quadruplet ○ D-RVd^* ○ Clinical trial	High risk vs standard risk • Cytogenetics ○ Hypoploidy ○ Hyperploidy • Fluorescence in situ hybridization ○ Del 17p, t(4;14), t(14; 16), t(14;20), gain 1q, loss 1p • Next-generation sequencing • Genomic expression profiling	Renal disease • Cast nephropathy • Nonmalignant etiology • Severity • Medication toxicity
Alkylator^† • Bendamustine • Cyclophosphamide Anthracycline • Doxorubicin • Doxil	Time to relapse • Early (<12 mo vs <24 mo) • Late (>48 mo) • Slow (asymptomatic/biochemical) • Rapid (symptomatic)	Neuropathy • MM related • Nonmalignant etiology
Proteasome inhibitor • Bortezomib • Carfilzomib • Ixazomib	Extramedullary disease • Plasmacytomas ○ Visceral ○ Skin • Central nervous system disease	Bone lesions (symptomatic vs asymptomatic)
ASCT • Transplant ineligible • Transplant eligible	Peripheral blood plasma cells • <5% • >5% • >20%	Steroid (tolerant vs intolerant)
Institutional/resources • Advanced cancer care center • Community medical center		Non-MM-related health conditions • Cardiovascular • Renal disease

Based on the GRIFFIN trial, a phase 2 trial; the phase 3 (PERSEUS) trial needed to support FDA approval of the quadruplet regimen is ongoing.

Some patient cases require induction triplet inclusive of traditional chemotherapeutic agent, for various reasons, such as renal insufficiency.