Treatment of multiple myeloma in 2021

Abstract

The treatment of multiple myeloma (MM) has evolved significantly in the recent years. The following are considered to be the major milestones which have led to a substantial improvement in prognosis: a shift of treatment to early (asymptomatic) disease stage, an emphasis on achieving negativity of minimal residual disease as well as the development of novel drugs with a biological mechanism of action. The novel drug classes used in the treatment of MM particularly include proteasome inhibitors (bortezomib, carfilzomib, ixazomib), immunomodulatory drugs (thalidomide, lenalidomide, pomalidomide), and monoclonal antibodies (daratumumab, elotu-zumab, isatuximab). Newly diagnosed patients eligible for intensive treatment are indicated to receive induction immunochemotherapy followed by high-dose melphalan supported by autologous stem cell transplantation and long-term maintenance therapy with lenalidomide. The treatment recommended in non-transplantable patients is long-term as well; the regimens recommended are Dara-VMP (daratumumab, bortezomib, melphalan, prednisone), DRD (daratumumab, lenalidomide, dexamethasone), and VRD (bortezomib, lenalidomide, dexamethasone). For patients with relapsed and refractory disease, novel treatment combinations are available, based on algorithms derived from the previous treatment and refractoriness to the drugs administered. The key determining factors particularly include relapse aggressive-ness, previous treatment and its effect, and the patient’s general condition. Combination regimens with lenalidomide currently have the best efficacy. In the case of refractoriness to lenalidomide or higher-line treatment, the general rule is the choice of a drug / drug group which has not been used in previous treatment phases. In late, multirefractory disease stages, the prognosis is unfavourable and the choice of therapeutic approach is challenging. The development of novel drugs and, in particular, immunotherapy brings great promise.