Prophylactic measures to prevent infectious complications during treatment with BCMA-targeting BsAb and CAR T-cell therapy (for general screening and vaccination strategies in MM, including the rationale, please refer to Ludwig et al41 and Raje et al.42)
| Screening before treatment: (A) hepatitis B: If positive for antibodies (or HBsAg negative, but anti–HBc positive), then test for hepatitis B DNA. (B) hepatitis C: If positive for antibodies, then test for hepatitis C RNA (C) HIV. . | |||
|---|---|---|---|
| Prophylaxis . | Agent . | Timing . | Additional comment . |
| Bacteriala | According to local policy, consider to add levofloxacin for 3 months in high-risk patients based on the results of the TEAMM trial69 | During neutropenia | Consider prophylactic therapy in case of recurring respiratory infections, according to local guidelines and antibiogram. |
| Viral | |||
| Herpes simplex and zoster | Valaciclovir 500 mg twice daily | Throughout treatment | Continue for 3 months of treatment or until CD4 cell count >200/µl. |
| Fungal | According to local policy or azole | During neutropenia | Also consider in patients with a previous history of fungal infection or glucocorticoid therapy. |
| PJP | Trimethoprim/sulfamethoxazole, or in case of allergy; atovaquone or pentamidine inhalation | Throughout treatment | Continue until CD4 cell count >200/µl. |
| IGRT | If IgG levels <400 mg/dLb | Throughout treatment | Continue even off therapy as long as IgG levels <400 mg/dL. |
| Screening before treatment: (A) hepatitis B: If positive for antibodies (or HBsAg negative, but anti–HBc positive), then test for hepatitis B DNA. (B) hepatitis C: If positive for antibodies, then test for hepatitis C RNA (C) HIV. . | |||
|---|---|---|---|
| Prophylaxis . | Agent . | Timing . | Additional comment . |
| Bacteriala | According to local policy, consider to add levofloxacin for 3 months in high-risk patients based on the results of the TEAMM trial69 | During neutropenia | Consider prophylactic therapy in case of recurring respiratory infections, according to local guidelines and antibiogram. |
| Viral | |||
| Herpes simplex and zoster | Valaciclovir 500 mg twice daily | Throughout treatment | Continue for 3 months of treatment or until CD4 cell count >200/µl. |
| Fungal | According to local policy or azole | During neutropenia | Also consider in patients with a previous history of fungal infection or glucocorticoid therapy. |
| PJP | Trimethoprim/sulfamethoxazole, or in case of allergy; atovaquone or pentamidine inhalation | Throughout treatment | Continue until CD4 cell count >200/µl. |
| IGRT | If IgG levels <400 mg/dLb | Throughout treatment | Continue even off therapy as long as IgG levels <400 mg/dL. |
Bacterial prophylaxis is risk adapted, based on age, frailty, Eastern Cooperative Oncology Group score, comorbidities, tumor burden, and type of therapy. For a detailed risk definition, please refer to Raje et al.42 Treatment with BsAb and CAR T-cell therapy can be considered high risk, especially during the first cycles of BsAb therapy or the use of glucocorticosteroids.
For CAR T-cell therapy the IMWG guidelines state: “The use of replacement immunoglobulins (intravenous or subcutaneous immunoglobulin) is controversial, given the absence of clinical trial data, but can be considered in patients with severe HGG (IgG levels <400 mg/dL) or in those with moderate HGG (IgG levels 400–600 mg/dL) and recurrent or severe infections.”
Adapted with permission from Rodriguez-Otero et al,29 Raje et al,66 Ludwig et al,67 and Lin et al.68