What should I consider when prescribing maintenance therapy, and is it appropriate for all patients?

FAQ Library published on November 8, 2018
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Sarah A. Holstein, MD, PhD
Associate Professor
Division of Oncology and Hematology
Department of Internal Medicine
University of Nebraska Medical Center
Omaha, Nebraska

Welcome to Managing Myeloma, I'm Dr. Sarah Holstein. Today I'd like to discuss the factors to consider when prescribing maintenance therapy and whether maintenance therapy is appropriate for all patients. I'll start with the caveat that I'll be discussing maintenance therapy in the context of post-autologous stem cell transplant.

What we know from a number of recent studies is that maintenance therapy can, in fact, improve not only progression-free survival but also overall survival following transplant, particularly in the context of lenalidomide maintenance therapy where we have the highest level of evidence. Often both patients and physicians ask whether they truly require maintenance therapy, and my answer is almost universally yes. This is because despite the fact that we have new drugs in the induction setting and the deepening of response that we have with transplant, patients will continue to relapse after transplant. I think it's really important to try to improve not only progression-free survival but also overall survival after transplant and, thus far, maintenance therapy post‑transplant has been able to achieve that goal.

The factors that we think about when prescribing maintenance therapy include some patient-specific factors — is the maintenance therapy something that they will be able to tolerate and is it something that they will be able to continue for a long time? From a disease perspective we want to make sure that we're giving something that will actually be effective against their myeloma. For the most part, lenalidomide maintenance post‑transplant has become standard of care for nearly all patients. There are a few cases where we would not use lenalidomide maintenance. That might be in a patient who previously could not tolerate the agent – perhaps those patients who very rarely get a very serious rash with the drug – or perhaps in other cases where patients progressed on lenalidomide as part of their induction treatment. Otherwise, however, I strongly recommend maintenance therapy post-transplant.

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Last modified: October 23, 2018
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