Multiple Myeloma Clinical Practice Guidelines (EHA/ESMO, 2021)

European Hematology Association/European Society for Medical Oncology

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

April 01, 2021

Clinical guidelines on the management of multiple myeloma (MM) were published in February 2021 by the European Hematology Association and the European Society for Medical Oncology in HemaSphere.[1]

Watchful waiting is recommended for patients with standard- or intermediate-risk smoldering MM (SMM). Participation in randomized phase 3 trials should be encouraged for those with high-risk SMM.

Induction therapy followed by high-dose melphalan (HDM) and autologous stem cell transplantation (ASCT) is recommended for patients with newly diagnosed MM who are younger than 70 years and have no comorbidities. Induction should consist of 4-6 cycles.

Among the triplet regimens used for primary induction therapy before transplantation, bortezomib/lenalidomide/dexamethasone (VRd) may have the best risk-benefit profile. The four-drug combination daratumumab/bortezomib/thalidomide/dexamethasone is considered a new standard of care for induction.

The recommended conditioning regimen before ASCT consists of HDM (200 mg/m2).

After ASCT, the standard of care for all patients is maintenance therapy with lenalidomide; however, bortezomib may be considered for those with high-risk MM.

For patients with MM who are not transplant candidates, the following regimens are considered the new standards of care:

  • VRd

  • Daratumumab/bortezomib/melphalan/prednisone

  • Daratumumab/lenalidomide/dexamethasone

Transplantation may be considered as second-line therapy for those who received primary ASCT followed by lenalidomide maintenance therapy and whose initial remission lasted at least 36 months.

A regimen based on the combination of lenalidomide and dexamethasone is recommended as second-line therapy for patients who initially received bortezomib-based therapy without lenalidomide or daratumumab.

Options for second-line therapy for patients who did not respond initially to lenalidomide are as follows:

  • Pomalidomide/bortezomib/dexamethasone

  • Daratumumab/carfilzomib/dexamethasone

  • Isatuximab/carfilzomib/dexamethasone

  • Daratumumab/bortezomib/dexamethasone

An appropriate second-line regimen for patients with t(11;14) who did not respond to lenalidomide and are sensitive to proteasome inhibitors is venetoclax/bortezomib/dexamethasone.

For more information, please go to Multiple Myeloma.

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