67-year-old patient progressed after having two bone marrow transplant in 2017 and then 2020. First induction regimen was VRD with Revlimid maintenance and second induction regimen was KPD with Pomalyst maintenance for 2 years and then had progression 2021 that was treated with Darzalex Pomalyst and Decadron till now when he has more progression. What should be next Treatment option? otherwise he is healthy, no residual toxicity, only issue in neutropenia ranging around 1000 with thrombocytopenia 70-80k.
Is this patient close to a center that offers CART or bispecifics? Those would be ideal. Let’s assume though that this patient can’t get on a commercial CART waiting list, or can’t get on a CART trial- my recommendation would be to use carfilzomib based regimen- as he used it for induction prior to second transplant but isn’t refractory to it. In these situations, I have used carfilzomib/cytoxan/dex but then used it as a bridge to something- getting them on a CART trial. You could also consider carfilzomib/Selinexor/dexamethasone. I wouldn’t use belantamab unless you’re sure this patient won’t get CART since it decreases chance of CART being successful. Hope this was helpful! Also, teclistamab will likely be approved by the FDA and using a carfilzomib based regimen will buy you time until then.
