Characterization of dysgeusia and xerostomia in patients with multiple myeloma treated with the T-cell redirecting GPRC5D bispecific antibody talquetamab

Perspectives on Outpatient Delivery of Bispecific T-Cell Engager Therapies for Multiple Myeloma

In the past few years, a new promising therapy, called bispecific T-cell engager (TCE), has been developed and is now available in many countries for patients with relapsed or refractory multiple myeloma. T-cell engagers are associated with sustained efficacy and progression-free survival benefits in patients with heavily treated myeloma. However, complications such as cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and infections complicate their administration, particularly in remote centers. This review discusses the key requirements for delivering TCEs therapies, focusing on outpatient delivery. We also outline the primary acute and chronic complications of TCE therapy and their management.

Supportive care in myeloma-when treating the clone alone is not enough

The overall survival in patients with multiple myeloma has increased over recent decades. This trend is anticipated to further advance with the emergence of T-cell-redirecting therapies, including chimeric antigen receptor T-cell (CAR T) therapy and T-cell-engaging bispecific antibodies. Despite these therapeutic improvements, treatment-related adverse events impede quality of life. This underscores the imperative of optimizing supportive care strategies to maximize treatment outcomes. Such optimization is crucial not only for patient well-being but also for treatment adherence, which may translate into long-term disease control. We here describe a) how to prevent bone disease, b) a risk-adapted thrombosis prophylaxis approach, c) the management of on-target, off-tumor toxicity of G-protein-coupled receptor class C group 5 member D-targeting T-cell-redirecting therapies, and d) infectious prophylaxis, with a focus on infections during T-cell-redirecting therapies.

Management of Toxicities Associated with BCMA, GPRC5D, and FcRH5-Targeting Bispecific Antibodies in Multiple Myeloma

PURPOSE OF REVIEW

The introduction of bispecific antibodies is one of the most significant recent advances in the treatment of relapsed/refractory multiple myeloma. This review will summarize the management of the toxicities associated with newly approved T cell-engaging bispecific antibodies and those which may be approved in the near future.

RECENT FINDINGS

Numerous trials have shown that bispecific antibodies can be both effective and tolerable when adverse events are properly managed. Cytokine release syndrome and increased infections are observed across all bispecific antibodies. Additional adverse events are target-specific, such as the more severe hypogammaglobulinemia and infections of BCMA bispecific antibodies and the dysgeusia, nail dystrophy, and skin changes of GPRC5D bispecific antibodies. Bispecific antibodies will surely become a mainstay of multiple myeloma therapy given their efficacy and accessibility. Their unique toxicities must be carefully considered and managed to ensure they are utilized safely.

T Cell-Redirecting Bispecific Antibodies in Multiple Myeloma: Optimal Dosing Schedule and Duration of Treatment

T cell-redirecting bispecific antibodies (BsAb) induce significant responses in heavily pretreated multiple myeloma. BsAbs are currently administered in a dose-dense manner until disease progression. However, continuous therapy is associated with safety concerns, including a high risk of infections and high costs. In addition, chronic exposure to BsAbs, and thus long-term T-cell stimulation, induces T-cell exhaustion, which may contribute to relapse. There is increasing evidence that the strategy of induction treatment followed by maintenance with longer intervals between BsAb doses, or limited treatment duration with cessation of therapy in patients who achieve deep remission, improves the balance between toxicity and efficacy. Significance: There is increasing evidence that after initial debulking, less-frequent BsAb administration mitigates T-cell exhaustion and minimizes the potential for chronic or cumulative toxicity while maintaining durable clinical responses. In addition, specific patient subsets may experience an extended treatment-free period following fixed-duration treatment. Fixed-duration treatment may, therefore, decrease cumulative toxicities and the burden on patients and healthcare systems.

[Research progress in targeting GPRC5D for the treatment of multiple myeloma]

Multiple myeloma (MM) is a malignant disease caused by the abnormal clonal proliferation of plasma cells, accounting for 10% of all hematologic cancers. In recent years, with the development and application of targeted drugs, a significant progress has been observed in the treatment methods of MM, but patients still face the challenges of relapse and drug resistance. Moreover, G protein-coupled receptor class C Group 5 member D (GPRC5D) is highly expressed in MM cells independently of B cell maturation antigen (BCMA) and is a highly promising target following BCMA. Aside from emphasizing the therapeutic efficacy and safety of targeting GPRC5D for the treatment of MM, this study also provides a prospective view on the mechanisms of drug resistance and relapse associated with GPRC5D-targeted therapies, as well as the timing of sequential or combined treatment strategies involving the dual targeting of both GPRC5D and BCMA.

T-cell redirecting bispecific antibody treatment in multiple myeloma: current knowledge and future strategies for sustained T-cell engagement

INTRODUCTION

T-cell redirecting bispecific antibodies (BsAbs), targeting B-cell maturation antigen (BCMA) or G-protein - coupled receptor class C group 5 member D (GPRC5D), are efficacious new agents for the treatment of patients with relapsed or refractory MM.

AREAS COVERED

This review discusses the pharmacokinetic properties, efficacy, and safety profile of T-cell redirecting BsAbs in MM, with a special focus on their optimal dosing schedule, resistance mechanisms and future strategies to enhance efficacy, reduce toxicity, and maximize duration of response.

EXPERT OPINION

To further improve the efficacy of BsAbs, ongoing studies are investigating whether combination therapy can enhance depth and duration of response. An important open question is also to what extent response to BsAbs can be improved when these agents are used in earlier lines of therapy. In addition, more evidence is needed on rational de-intensification strategies of BsAb dosing upon achieving a sufficient response, and if (temporary) treatment cessation is possible in patients who have achieved a deep remission (e.g. complete response or minimal residual disease-negative status).

Bispecific Antibody Use in Patients With Lymphoma and Multiple Myeloma

This article endeavors to navigate the clinical journey of bispecific antibodies (BsAbs), from elucidating common toxicities and management strategies to examining novel agents and broadening access in community health care. These drugs, commonly through T-cell activation, result in shared adverse events such as cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. Variations in target antigens and designs, however, might introduce unique toxicities for different BsAbs, warranting specific management approaches. Recent US Food and Drug Administration approvals of BsAbs targeting CD3+ T cells linked to CD20 for non-Hodgkin lymphoma and to B-cell maturation antigen or GPRC5D for multiple myeloma have transformed the treatment landscape for hematologic malignancies. Emerging new agents promise further enhancement and safety, exploring novel antigen targets, innovative structures such as trispecific antibodies, and the engagement of diverse immune cells. Simultaneously, the expansion of BsAbs into community practices is underway, demanding a multifaceted strategy that encompasses educational initiatives, operational adaptations, and collaborative frameworks. This ensures comprehensive treatment access, allowing every patient, irrespective of geographical or socioeconomic status, to benefit from these advancements in cancer therapy.

Supportive care measures for bispecific T-cell engager therapies in haematological malignancies

PURPOSE OF REVIEW

Bispecific T-cell engager (TCE) therapies are revolutionising the treatment of several haematological malignancies, including B-cell acute lymphoblastic leukaemia, various subtypes of B-cell non-Hodgkin lymphoma, and multiple myeloma. Due to their unique mode of action in activating endogenous T cells, they are associated with several important early side effects, including cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. In addition, TCEs can cause target-specific toxicities and carry a significant risk of infection.

RECENT FINDINGS

Currently, supportive care measures for TCEs have largely been inferred from other T-cell therapies, such as CAR-T (chimeric antigen receptor) therapy. Further research into TCE-specific supportive care measures is needed to improve the tolerability of these therapies for patients. A key question moving forward is understanding how to predict and minimise early toxicity (cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome). Associated infection risk is a significant cause of patient morbidity, therefore a better understanding of how to optimise TCE-dosing and prophylactic measures, such as intravenous immunoglobulin and antimicrobials, will be crucial to achieving an improved balance of toxicity and efficacy. Enabling early outpatient delivery of these therapies to select patients at lower risk of toxicity may also help to improve patient experience and quality of life.

SUMMARY

Here we review up-to-date guidance and literature on existing supportive care measures for bispecific TCE therapy-related toxicities. We highlight both unique and serious side effects of TCE therapies that require improved management strategies to enable more patients to benefit from these efficacious drugs.