Treatments for transplant ineligible multiple myeloma

People with active multiple myeloma have symptoms related to the disease. Your healthcare team will first decide if you can have a stem cell transplant. If you can't have a stem cell transplant, this is called transplant ineligible multiple myeloma. If you can have a stem cell transplant, this is called transplant eligible multiple myeloma. Find out more about treatments for transplant eligible multiple myeloma.

You are considered transplant ineligible if you don't meet the criteria set by your treatment centre, but it usually means you are older than 70 years of age or you have other health conditions (called comorbidities).

The goals of treatment for transplant ineligible multiple myeloma are to minimize symptoms and to achieve the best possible response to treatment with as little toxicity as possible. Your own goals for treatment are also important.

There are 2 main phases of treatment for transplant ineligible multiple myeloma.

Induction therapy is the first phase of treatment for multiple myeloma. The goal of induction therapy for multiple myeloma is to lower the number of abnormal plasma cells (called myeloma cells) in the bone marrow and the number of M-proteins made by the myeloma cells. Induction therapy often includes targeted therapy and other drugs such as chemotherapy or corticosteroids or both.

Maintenance therapy is given after other treatments to help multiple myeloma stay in remission. Maintenance therapy is used after induction therapy for transplant ineligible multiple myeloma. The drugs used in maintenance therapy are usually targeted therapy drugs.

The following are treatment options for transplant ineligible multiple myeloma. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Induction therapy is the first phase of treatment for multiple myeloma. The goal of induction therapy for multiple myeloma is to lower the number of myeloma cells in the bone marrow and the number of M-proteins made by the myeloma cells. Induction therapy is usually given for several months.

The following drug combinations may be used for induction therapy for transplant ineligible multiple myeloma:

• DRd – daratumumab (Darzalex), lenalidomide (Revlimid) and low-dose dexamethasone
• RVD – lenalidomide, bortezomib (Velcade) and dexamethasone
• Dara-CyBorD – daratumumab, cyclophosphamide, bortezomib and dexamethasone
• CyBorD – cyclophosphamide, bortezomib and dexamethasone
• Rd – lenalidomide and low-dose dexamethasone
• VD – bortezomib and dexamethasone
• IRd – ixazomib (Ninlaro), lenalidomide and low-dose dexamethasone

These drugs may not be covered by all provincial and territorial health plans.

Induction therapy for transplant ineligible multiple myeloma is usually given until there are signs that the disease is progressing or you are unable to manage the treatment side effects (called continuous therapy). It can also be given for specific time, such as 2 to 3 years, and then stopped (called time-limited or fixed-duration therapy).

Find out more about targeted therapy for multiple myeloma and chemotherapy for multiple myeloma.

Maintenance therapy is used after induction therapy for transplant ineligible multiple myeloma. A maintenance therapy drug is usually given in a low dose over a long period of time. This helps to keep multiple myeloma in remission and prevent relapse. Because the drug is given at a low dose, there tends to be fewer side effects and you’re able to have a better quality of life.

The following drugs and drug combinations may be used for maintenance therapy for transplant ineligible multiple myeloma:

• lenalidomide (Revlimid)
• lenalidomide and bortezomib (Velcade)
• ixazomib (Ninlaro)

If you have the DRd regimen for induction therapy, maintenance therapy is not needed.

Find out more about targeted therapy for multiple myeloma.

Supportive therapy is used to prevent or control health problems and complications related to multiple myeloma. You may have the following supportive therapy drugs during the 2 phases of treatment for transplant ineligible multiple myeloma.

Drugs to slow down bone loss– Everyone with multiple myeloma is usually given either a bisphosphonate, such as zoledronic acid (Aclasta, Zometa) or pamidronate, or a drug called denosumab (Prolia, Xgeva and biosimilars) . These drugs help to slow down bone loss and keep your bones strong.

Drugs to prevent blood clots– Lenalidomide can increase your risk of serious blood clots. You will be given drugs that help prevent blood clots, such as acetylsalicylic acid (ASA, Aspirin), heparin or warfarin, if your treatment includes lenalidomide.

Drugs to prevent infection– Drugs used to treat multiple myeloma increase your risk of infection. Antibiotics are often given to help prevent infection.

Find out more about supportive therapy for multiple myeloma.

You may be asked if you want to join a clinical trial for multiple myeloma. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don't work anymore, they're not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can't have or don't want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.