4
Treatment
➤ The quality and depth of response should be assessed by
IMWG (International Myeloma Working Group) criteria. (Strong
Recommendation; EB-H-B)
➤ The goal of initial therapy for transplant eligible patients should be
achievement of the best depth of remission. MRD negative status has
been associated with improved outcomes, but it should not be used to
guide treatment goals outside the context of a clinical trial. (Moderate
Recommendation; EB-H-B)
➤ It is recommended that depth of response be assessed with each
cycle. Frequency of assessment once best response is attained or
on maintenance therapy may be assessed less frequently but at
minimum every 3 months. (Weak Recommendation; EB-L-B)
➤ Whole-body low dose CT scan has been shown to be superior to
skeletal survey done with plain x-rays and is the preferred method for
baseline and routine bone surveillance. FDG-PET/CT and/or MRI may
be used as alternatives at baseline. They may also be used in select
situations (e.g. risk stratifying smoldering myeloma, for monitoring
response of non-secretory and oligosecretory myeloma and if CT or
skeletal survey is inconclusive). (Moderate Recommendation; EB-H-B)
Transplant Ineligible
➤ Initial treatment recommendations for patients with multiple
myeloma who are transplant ineligible should be individualized based
on shared decision-making between physicians and patients. Multiple
factors should be considered; disease-specific factors such as stage
and cytogenetic abnormalities, patient-specific factors including
age, comorbidities, functional status, frailty status and patient
preferences should also be considered. (Strong Recommendation;
EB-I-B)
➤ Initial treatment for patients with multiple myeloma who are
transplant ineligible should include at minimum a novel agent
(immunomodulatory drug or proteasome inhibitor) and a steroid if
possible. (Strong Recommendation; EB-H-B)
➤ Triplet therapies for patients with multiple myeloma who are
transplant ineligible, including bortezomib-lenalidomide-
dexamethasone should be considered. Daratumumab + bortezomib
+ melphalan + prednisone may also be considered. (Strong
Recommendation; EB-H-B)
