Have a 72 yr old female with pmh of unprovoked DVT in 2018 with new diagnosis of IgG lambda myeloma. Workup prompted by elevated protein and anemia. PET/CT negative. Renal function intact. Cytogenetics: t(4;14). FISH negative. ECOG around 2. No hx of heart failure. Wanted to ask for an elderly frail patient like her what treatment do you typically recommend? Also how do you sequence patients on DRd once they reach Dara q4 weeks maintenance. Do you drop the Revlimid and continue with Dara alone or change Revlimid dosing?
Daratumumab is a great drug for the more frail patients. However, with the presence of t(4;14), a proteasome inhibitor should also be considered since these patients really benefit from it. You can try a dose modified version of Dara-RVD with dara SQ, revlimid 10-15mg d1-21, velcade SQ d1, 8, 15 and dex 20mg weekly. If difficulty with tolerability, can dose modify further or stop one of the agents. One we get to maintenance, usually continue dara monthly with low dose rev at 10mg d1-21.