Novel drug combinations for the management of relapsed/refractory multiple myeloma

The outcomes and management of multiple myeloma (MM) in the United States have changed dramatically over the past 15 years with the approval by the US Food and Drug Administration (FDA) of 6 new drugs (thalidomide, lenalidomide, bortezomib, pegylated liposomal doxorubicin [Doxil], carfilzomib, and pomalidomide). Despite these advances, a majority of patients with MM relapse, requiring subsequent lines of therapy to manage their disease as a chronic condition. Even though oncologists recognize the heterogeneity in the biology and clinical presentation of patients with newly diagnosed MM, clinical investigations still approach MM in a one-size-fits-all manner. The clinical management becomes even more challenging for relapsed/refractory MM, in which the clinician is balancing disease biology, disease burden, host factors, and financial limitations. There are several new drug targets and antibodies making their way through clinical development, but clinical trials remain an important avenue for patients with relapsed/refractory MM. The present review highlights some of the novel agent combinations in clinical trials that include the 2 most recently approved anti-MM agents, carfilzomib and pomalidomide, and looks ahead toward new drugs and targets in myeloma.

Multiple myeloma: Updates for pharmacists in the treatment of relapsed and refractory disease

There have been a number of recent advances in the treatment of patients with relapsed and refractory multiple myeloma. However, despite additional FDA-approved therapies including carfilzomib and pomalidomide as well as clinical trials investigating new combinations of existing treatments, multiple myeloma remains an incurable disease. New therapies currently in the drug development pipeline for relapsed and refractory disease include additional proteasome inhibitors (oprozomib, marizomib, ixazomib), histone deacetylase inhibitors (panobinostat, ricolinostat, quisinostat), monoclonal antibodies (daratumumab, elotuzumab, SAR650984), Bruton's tyrosine kinase inhibitors (ibrutinib), a selective inhibitor of nuclear export, and others. This review will focus on these newly developing therapies as well as the ever expanding role of the pharmacist in supportive care for patients with relapsed and refractory multiple myeloma.

Management of double-refractory multiple myeloma

Widespread use of the novel agents bortezomib and lenalidomide has improved outcomes in multiple myeloma (MM). Despite remarkable progress, patients will eventually relapse after exhausting treatment with these drugs. Management of myeloma that is refractory to both bortezomib and lenalidomide (double-refractory MM, DRMM) is complicated due to disease, patient, and treatment-related factors and new therapies for these patients are required. A review of the unique challenges of treating DRMM, recently FDA-approved therapeutic agents, and selected novel drugs under active clinical investigation, is presented below.