The pharmacologic management of multiple myeloma in older adults

ABSTRACT

Introduction: Multiple myeloma is a disease predominately affecting older adults. Pivotal to treating older adults is understanding their physiologic differences compared to younger subjects and how the complexity of therapies has an impact upon this patient population.

Areas covered: Herein, the authors address the efficacy of chemotherapy regimens, decision-making for older adults, chemotherapy-associated toxicity and the approach to management. This review focuses on the complex treatment of older multiple myeloma patients and management of treatment-related adverse events.

Expert opinion: Balancing efficacy and managing toxicity is a challenge for older myeloma patients. This group is more susceptible to treatment toxicities due to a higher incidence of pre-existing comorbidities and underlying diminished physiologic reserve. Intensive therapies such as autologous hematopoietic cell transplant (AHCT), however, still should be considered for all multiple myeloma patients, including older adults. The continued development of novel therapies and increased use of multi-drug regimens has changed the treatment paradigms yet understanding the complexity of the aging adult in the context of various drugs is warranted.

KEYWORDS:

• Multiple myeloma
• older adult
• toxicity
• novel agents
• hematopoietic cell transplant
• hematology

Article highlights

• Older adults with myeloma are more susceptible to treatment toxicities due to a higher incidence of pre-existing comorbidities and underlying diminished physiologic reserve

• Intensive therapies, including autologous hematopoietic cell transplant, should be considered for all myeloma patients, including older adults

• With an acceptable safety profile, the three drug regimen of bortezomib, lenalidomide, and dexamethasone (VRd) has become the current standard of care induction regimen for newly diagnosed multiple myeloma patients and established the superiority of a three-drug vs two-drug regimen

• VRd may successfully be given to older adults with appropriate dose and schedule modifications such weekly bortezomib administration combined with dose reductions in lenalidomide and dexamethasone

• Although the sequencing of use of novel agents remains unknown, daratumumab, elotuzumab, and venetoclax are effective and tolerable therapeutic options for older adults with myeloma

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Declaration of interest

H Lazarus has acted a promotional speaker for Celgene and Bristol-Myers Squibb. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This manuscript was not funded.